GL & Product Liability Questionnaire

Print this form and fax it to Security Risk Managers at 615-369-1526 or it mail to: Security Risk Managers, 50 Vantage Way, Nashville, TN 37288.

1.	Name of Insured:
2.	Mailing Address:
3.	Phone/Fax Numbers:
4.	Contact:
5.	Current Premium:
6.	Current Primary Carrier/Deductible:
7.	Current Umbrella Carrier/Limit:
	Effective Date:
8.	How many years has insured been in business
9.	Describe Products:
10.	Does Insured manufacture complete product?
11.	Does Insured assemble product:
12.	Does Insured maintain quality control procedures?
13.	Does Insured miantain/service products?
14.	Does Insured keep inventory records of shipments?
15.	Are serial/batch numbers shown on finished products?
16.	Can date of manufacture of product be identified?
17.	Do you keep samples of products?
18.	Estimated Payroll for next 12 months: $
	Estimated Sales next 12 months:
	Domestic: $
	Foreign: $
19.	Show sales for previous 5 years:
	Year Gross Sales No. of Units
20.	Has Insured ceased to manufacture any products during the past 5 years? If so, give description and details.
21.	Are any products subject to deterioration?
22.	Are guarantees/warranties issued to purchasers?
23.	Attach products brochures.
24.	Claims Histories Excess of $10,000 (past 5 years):
	Year Claims Paid   Reserves Open   Number Paid Number Amount
25.	Any incidents, not reserved, that may result in claims against insured?
26.	What limits of liability are required?
27.	What deductibles are required?
28.	What past/present deductibles have applied?
29.	Narrative of any claims excess $25,000 or additional comments on any other questions: