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Intermediary: ________________________
NOTICE TO THE PROPOSED INSURED Your Duty of Disclosure
A. Your attention is drawn to your duty of disclosure, as follows:
(1) An Insured has a duty to disclosure to the Insurer, before the relevant contract of insurance is entered into, every matter that is known to the Insured being a matter that:
(a) the Insured knows to be a matter relevant to the decision of the Insurer whether to accept the risk, and if so, on what terms, or
(b) a reasonable person in the circumstances could be expected to know to be a matter so relevant.
(2) the duty of disclosure does not require the disclosure of a matter: (a) the diminishes the risk,
(b) that is of common knowledge,
(c) that the insurer knows or in the ordinary course of his/her business as an Insurer ought to know, or
(d) as to which compliance with the duty of disclosure is waived by the Insurer. (3) Where a person:
(a) fails to give an answer, or
(b) gives an obviously incomplete or irrelevant answer to a question included in a proposal form about a matter,
the Insurer shall be deemed to have waived compliance with the duty of disclosure in relation to the matter.
B. Non-Disclosure
If you fail to comply with your duty of disclosure, we may be entitled to reduce our liability under the contract in respect of a claim or may cancel the contract.
If your non disclosure is fraudulent, we may also have the option of avoiding the contact from its beginning
If insufficient space on this form, please use an attachment page.
1. The Insured
a. Full name of proposed Insured including subsidiaries Company Name
QBE PRODUCT LIABILITY PROPOSAL FORM
b. Postal Address
c. Full description of your operations and activities.
d. Number of years in continuous business
2. Policy Requirement
a. Period of Insurance:
From / / At 12.00 noon local standard time
To / / At 12.00 noon local standard time
b. Limit of Indemnity:
Product liability $ in the aggregate for all Injury and/or
Damage during the Period of Insurance c. Deductible Required
$
3. Estimated Payroll (including earnings of principals, directors, partners)
No. of Staff
Management, Clerical and Sales $
Manufacturing $
Installation / work away from premises $ Payment to contractors and/or sub-contractors $
Others (please specify) $
Total $
4. Product Information / Estimated Annual Turnover
Please give details of all products in respect of which insurance required. a.
Description of Product (M) Manufacture (I) Import
Total
Turnover( $ )
Exports ( $ ) Destination
(D) Distribute
TOTAL
THE PRODUCTS:
List of the products manufactured (imported) or goods sold:
Please attach any product Brochure (s) and other descriptive documents, Annual Reports or other material if applicable.
b. Do you currently or have you in the past been involved in the manufacture, distribution or sale of the following and t o your knowledge are any of the products used or incorporated in:
i. Aircraft (Including component Parts), Spacecraft and satellite Yes No
ii. Watercraft Yes No
iii. Atomic Reactors or Installations Yes No
iv. Petro Chemical Installations Yes No
v. Ethical Drug Yes No
vi. Class 1 Dangerous Group and ammunition Yes No
vii. Fertiliser Yes No
viii. Pesticides Yes No
ix. Fungicide Yes No
x. Liquid or gas fuel Yes No
xi. Radioactive material or any Yes No
xii. Any Product containing asbestos Yes No
xiii. Man-made or synthetic mineral fibres (eg. Fibreglass) Yes No
If “YES” please provide details including turnover:
c. Do You Design parts or compete components for others? Yes No d. Do you Manufacturer to design, formula, plans or specifications of others? Yes No e. If your product range relatively static or changing frequently both in regards to the quantity
and any type of products Yes No
f. Are you UNABLE to identify the source of supply of every item used in the manufacture of the
products? Yes No
g. Do you expect to manufacture any new products in the next 12 months? Yes No If answer is Yes to any of the above (c) to (g) please provide details
5. Do you have any overseas representation, office or sales organization ? Yes No If “YES”, please provide details
6. Installation:
a. Do you install or apply your own product/s or perform any services? Yes No If “YES” give details and state whether work is guaranteed:
b. What supervision is employed
7. In respect of Exports to the USA and Canada, Please advise:
a. Are you represented or do you have any assets within the USA or Canada? Yes No b. Does any one your Power of Attorney within the USA or Canada Yes No c. IS the Importer, Distributor, agent or purchaser insured for Product liability? Yes No d. Are you included as an Insured in such Contracts of Insurance Yes No e. Give Full details (including copies of contracts etc) of all contractual agreement, terms and
conditions existing between you and an US/ CANADIAN importer, distributor, agent or purchaser of the Product exported thereto.
f. Under what terms are the products exported (eg FOB)
g. How long have such product been exported to the USA or Canada
h. Pollution
i. Does your use and storage of all toxic substances comply with all statutory
Regulations and By-Laws? Yes No
ii. Do any of your trade processes produce toxic waste and other pollutants which have the potential to cause injury to persons or damage to property or otherwise harm the environment? Yes No If yes, please provide details
i. Does your waste disposal or waste storage comply with Government Regulations and By- Laws? Yes No
If yes, Please give full details of any chemicals, gases, explosives, radioactive or toxic substances used &/or stored
8. Please provide a list of discontinued products manufactured and/or distributed by you: Yes No If “YES”, please provide details of reason, type of products and year, etc
9. List the types of consumers to whom products or goods are sold and whether sold direct to public or through Wholesalers, Distributors or Retailers:
10. Raw Materials, Components or Supplies:
a. Describe raw materials, components or supplies used:
b. Are raw materials, components or supplies imported? Yes No
If “YES” give full details of Manufacturer or Supplier and Country of Origin.
11. Do any of your suppliers contract out of Liability? Yes No If “YES” give details:
12. Are the finished products:
a. Subject to any Local Standards Association or relevant international Codes? Yes No
b. Subject to any Statutory or other Regulations? Yes No
If “YES” give details and also state whether these are being complied with:
13. Do you
a. Impose Conditions of Sale? Yes No
b. Make any disclaimers of Liability? Yes No
c. Give any guarantee for your products? Yes No
If “YES” give details (please provide copies):
14. Have you ever had to withdraw or recall products from use? Yes No If “YES”, give details:
15. Do you have re-call procedures in place? Yes No
If “YES”, give details:
16. Are any of the products designed or formulated by your own staff? Yes No If “YES”, give details:
17. Quality Control:
a. What methods of Quality Control are adopted? ie Is each and every product i. Inspected Only?
ii. Tested only?
b. Are sampling techniques employed? Yes No
If “YES”, state degree of fault tolerated (if any), eg., 2 per 1,000 per hour per batch:
c. What tests and/or inspections are made on the samples?
d. Are batch samples retained and catalogued? Yes No
If so, for how long are they retained and records kept ?
e. What is the calculated number of defects in relation to output per product?
f. What is the maximum allowed by production manager?
g. What features, if any, are incorporated to ensure that defects are eliminated or reduced or specifications are complied with: Raw materials of the product ,
h. Can all of your products be identified as having been manufactured by yourself?
18. Containers:
How are the products packed eg. Glass, metal, cardboard etc?
19. Labels:
a. Do your products carry labels/packaging and/or information sheets, which provide instructions and/or information regarding the correct use or storage and/or warnings of potential hazards?
b. Do your labels/packaging and/or information sheets carry instructions in relation to medical treatment and/or remedial treatment/action to be taken in the event of an accident, consumption, or misuse of the product? Has the information or instructions contained on your labels, packaging and/or information sheets been tested and/or checked for accuracy?
c. Has the information/instructions contained on your labels, packaging and/or information
sheets been checked by a solicitor or lawyer? Yes No
20. Is coverage afforded by any other Policy of Insurance? Yes No If yes, please provide details
21. Professional Exposure
Do you provide any advice, design or specification to third parties
(a) For a fee Yes No
(no coverage is afforded unless specifically endorsed to the policy)
(b) for no fee Yes No
If yes, please provide details
22. Contractual Liability
Coverage for liability assumed under contract or agreement will be limited to lease liability or liability assumed under a warranty of illness or quality as regards your products, or specifically agreed contracts. Please give full details and attach copies of all agreements (other than lease liability) where you assume liability under contract or hold others harmless.
Coverage will be provided only if specifically agreed by QBE.
Do you assume liability under contract or hold others harmless (other than lease liability)?
Yes No If ‘Yes’, provide full details and attach copies of all agreements (other than lease liability).
23. History:
Have any legal proceedings every been initiated against the proposer in connection with any products or goods sold or services rendered by the proposer or any of its subsidiaries anywhere in
the world? Yes No
If “YES” give details
24. Claims and/or Loss Experience
After investigation please provide claims experience and/or uninsured loss experience over the last five years for losses and claims that would have been covered under the proposed insurance. Please show claim amount after the application of any excess.
Insurance Period No. Claims Reported
Amount paid and
outstanding
Applicable Excess
Description
__/__/__ to __/__/__ __/__/__ to __/__/__ __/__/__ to __/__/__ __/__/__ to __/__/__ __/__/__ to __/__/__
25. After investigation are there any circumstances of which you are aware
a. which could give rise to a claim under the proposed Policy and which are not mentioned above. Yes No If yes, please provide details
b. Is there any additional information or detail of which your are aware and which ay assist the Underwriter to better assess the nature of the risk? Yes No If yes, please provide details
26. Previous Insurance History
After investigation has any proposed insured ever had any:
(i) Insurance declined or cancelled? Yes No (ii)Renewal refused? Yes No (iii) Special conditions imposed? Yes No (iv) Increased excess imposed? Yes No (v) Claims denied for this class of insurance? Yes No If “YES” give details:
Declaration
I declare that to the best of my knowledge and belief the answers given above, documents or papers submitted, represent the true position and that I have not withheld any information material to this proposal. I agree that this proposal and accompanying documents or papers shall form or partly form the basis of the Contract proposed.
Signature(s): _______________________________ Date: ______________________________
Title: _____________________________________
