To receive a quick quote on your manufacturers coverage, please complete the form. The form fields in bold must be filled in prior to submitting the form. If you would prefer to mail or fax us your quote form, click here.

General Information
Company Name:
Contact Person:
Phone Number:
Fax Number:
Email Address:
Website:
Address:
City:
State:
Zip Code:
Current Insurance Carrier:
Current Expiration Date:
Current Annual Premium:
Years in Business:
Type of Business:	Corporation Proprietorship LLC

Specficied Products and Sales

Product Sold	% of Gross Sales
Product Sold	% of Gross Sales
Product Sold	% of Gross Sales
Product Sold	% of Gross Sales
Total gross sales or receipts for all products:
Past 12 Months
Next Year Projections

Processing and Quality Control
Do others manufacture, assemble, package or install products under your same name or label?	Yes No
Do you manufacture, assemble or package or install products for others under their name or label?	Yes No
Do you have a quality control and testing procedure?	Yes No
How long are quality control and testing records kept?	Yes No
Do you require certificates evidencing Products Liablitiy insurance from suppliers?	Yes No
Who designs your products?
Claims History
5 Years including any predecessor companies - insured or uninsured – Check if none
Total losses, included any deductible and/or defense. Please include a description of any losses over $10,000.
Year(s)
No. Claims
Total Amounts Paid
Amounts in Reserve
Total Incurred
Date of Loss Information
Are you aware of any other incidents, conditions, circumstances, defects or suspected defects which may result in claims against you? Yes No
If yes, please explain:
Other Comments:
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