Products Recall Supplemental Application

PRODUCTS RECALL EXPENSE APPLICATION

(Use this application in conjunction with Acord or other similar application)

PART I. APPLICANT INFORMATION

Name & Address of Organization:

Producer:

Policy Number:

Policy Period: to

PART II. COVERAGE / LIMITS

Aggregate Limit:

Participation Amount

Deductible Amount:

Cut Off Date (if applicable):

PART III. PRODUCT DESCRIPTION

Current Products Exposure: GL Description of Product Annual Sales Classification

Discontinued Products: GL Description Annual Last Reason Discontinued Classification Sales Year Mfgrd.

Are products sold: Internationally Countrywide Regionally Specify:

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PART IV. GENERAL INFORMATION (Explain all YES answers on a separate page)

1. Are any current or previous products government regulated? Yes No

2. Do any components of current or previous products contain heavy metals such as mercury, lead or uranium? Yes No

3. Are any products or components toxic, flammable or explosive? Yes No

4. Does the applicant have any knowledge or information of current or previous products which are now subject to a recall or that pose an immediate danger to others? Yes No

5. Are any products exempt or grandfathered from safety or legislative requirements? Yes No

6. Does the applicant have a recall plan of all products? Yes No

7. Are Quality Control tests regularly performed on products? Yes No

8. Are stock records kept by batch? Yes No

9. Do records include the name of downstream distributors, retailers or manufacturers? Yes No

10. Is data kept on incoming suppliers? Yes No

11. Are warranty records kept? Yes No

12. Are duplicate copies of records maintained at a premise other than the insured’s? Yes No

PART V: LOSS HISTORY List all previous recalls or occurrences that may give rise to recalls for the prior 5 years:

Date of Occurrence or Description of Product Amount Paid Recall

Applicant Signature: ______

Date: ______