Mourer Foster Nutraceutical Insurance Program - Affordable Insurance for Health & Fitness Professionals

* required fields

* Contact Person:

* Business Name:

Entity Type:

* Address:

* County:

* City:

* State: * Zip:

* Phone:

Fax:

* Email:

Web:

* Current Insurance Co.:

* Current Premium Payment:

Mo.

Qtr.

Half

Year

* Gross Revenue:

	Applicant Acts as a(n)							Products Sold to:
Products and Services (or specified categories)	M	W	R	I	MR	No. Years	% of Gross Reciepts	W	R	C	O

M: manufacturer W: wholesaler R: retailer I: importer
MR: manufacturer's rep. C: consumer direct O: other

Estimated annual gross receipts for the coming year:

Annual gross receipts last 12 months:

Annual gross receipts 1st prior year:

Is the Applicant presently considering any change in the mix of products including any new products or services for the coming year?:		Yes		No
Has the Applicant discontinued or is it considering discontinuing any product or service listed above?:		Yes		No

PROCESSING

Do and products or components thereof, originate from outside of the United States?:	Yes	No
If Yes, specify the country of origin:
The name of each organization manufacturer, distributer or supplier:

Do others manufacture or package products under the Applicant's name or label?:	Yes	No
If Yes, provide the name(s) of contract manufacturer(s):

Does the Applicant manufacture or package products for others under their name or label?;	Yes	No
If Yes, explain:

QUALITY CONTROL AND RECORDKEEPING

Does the Applicant have a quality control and testing procedure?:	Yes	No
If Yes, how long does the Applicant keep quality control and testing records?:

Can the Applicant identify its product(s) from those of competitors?:	Yes	No
Do all records show to whom and the date each product was sold?:	Yes	No
Does the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?:	Yes	No
Who designs Applicant's products?:
Are product designs reviewed, tested and verified by others?:	Yes	No
Does the Applicant have a specific program to withdrawn known or suspected defective products from the market?:	Yes	No
Has the Applicant ever recalled or is it considering recalling any product?:	Yes	No
Have any of the Applicants' products or ingredients or components thereof, ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any governmental, quasi-governmental, administrative, regulatory or oversight body?:	Yes	No

Limits of Liability requested: $	/	$

Indicate the deductable requested:		$

**The company does not guarantee to offer any of the above limits and/or deductables.

Has any insurer declined, canceled, or nonrenewed any Product Liability Insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?		Yes		No
If Yes, provide details:

Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last five (5) years?:	Yes	No
If Yes, be prepared to provide five (5) year loss history for all claims, including any predecessor. A description of any loss greater than $10,000 will be required.

Is (are) any person(s) or organizaition(s) proposed for this insurance aware of any fact, incident, circumstance, situation, condition, defect or suspected defect which may result in a Products Liability claim?:	Yes	No
If Yes, provide details: