<p>PRODUCTS RECALL EXPENSE APPLICATION</p><p>(Use this application in conjunction with Acord or other similar application)</p><p>PART I. APPLICANT INFORMATION</p><p>Name & Address of Organization: </p><p>Producer: </p><p>Policy Number: </p><p>Policy Period: to </p><p>PART II. COVERAGE / LIMITS</p><p>Aggregate Limit: </p><p>Participation Amount </p><p>Deductible Amount: </p><p>Cut Off Date (if applicable): </p><p>PART III. PRODUCT DESCRIPTION</p><p>Current Products Exposure: GL Description of Product Annual Sales Classification</p><p>Discontinued Products: GL Description Annual Last Reason Discontinued Classification Sales Year Mfgrd.</p><p>Are products sold: Internationally Countrywide Regionally Specify:</p><p>Page 1 of 2 PRODUCTS RECALL EXPENSE APPLICATION</p><p>PART IV. GENERAL INFORMATION (Explain all YES answers on a separate page)</p><p>1. Are any current or previous products government regulated? Yes No</p><p>2. Do any components of current or previous products contain heavy metals such as mercury, lead or uranium? Yes No</p><p>3. Are any products or components toxic, flammable or explosive? Yes No</p><p>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</p><p>5. Are any products exempt or grandfathered from safety or legislative requirements? Yes No</p><p>6. Does the applicant have a recall plan of all products? Yes No</p><p>7. Are Quality Control tests regularly performed on products? Yes No</p><p>8. Are stock records kept by batch? Yes No</p><p>9. Do records include the name of downstream distributors, retailers or manufacturers? Yes No</p><p>10. Is data kept on incoming suppliers? Yes No</p><p>11. Are warranty records kept? Yes No</p><p>12. Are duplicate copies of records maintained at a premise other than the insured’s? Yes No</p><p>PART V: LOSS HISTORY List all previous recalls or occurrences that may give rise to recalls for the prior 5 years:</p><p>Date of Occurrence or Description of Product Amount Paid Recall</p><p>Applicant Signature: ______</p><p>Date: ______</p><p>Page 2 of 2</p>