Product Liability Insurance Application - Alliance for Contractors
MEMBER INSURANCE SERVICES

Product Liability Insurance Application

Comprehensive Coverage for Manufacturing, Distribution & Installation

1. Company Information & Alliance Membership

Company Legal Name:
DBA/Trade Name:
Alliance Membership ID:
Primary Business Address:
Federal Tax ID (EIN):
Years in Business:
Alliance Membership Date:
Primary Contact Name:
Contact Phone:
Contact Email:

2. Product Manufacturing & Distribution Information

Annual Gross Revenue:
Product Revenue Percentage:

Primary Business Operations (Check all that apply):

Product Manufacturing
Product Distribution
Component Installation
Private Label Manufacturing
Custom Product Assembly

Detailed Product Description:

Primary Markets Served:
Geographic Distribution:

3. Component Installation & Supplier Details

Supplier/Vendor Name Product/Component Type Annual Purchase Volume Alliance Verified
Installation Services Provided:
Installation Team Size:
Subcontractor Usage:

Supplier Quality Control Measures:

4. Quality Control & Risk Management Systems

Quality Certifications (Check all that apply):

ISO 9001 Quality Management
ISO 14001 Environmental Management
OSHA Safety Compliance
Industry-Specific Certifications
Testing Laboratory Used:
Product Testing Frequency:
Quality Control Staff Count:

Defect Prevention Procedures:

Product Tracking & Documentation Systems:

Alliance Integration: Members utilizing Alliance-verified suppliers and quality tracking systems may qualify for premium discounts and enhanced coverage benefits.

5. Coverage Requirements

Coverage Type Requested Limit Current Coverage (if any) Priority Level
General Product Liability
Component Liability
Installation Defects
Product Recall Protection
Design Defect Coverage
Manufacturing Error Coverage
Preferred Policy Term:
Desired Coverage Start Date:
Preferred Deductible Amount:

6. Alliance Integration Features

Alliance Services Integration (Check desired features):

Automated Supplier Verification
Real-time Quality Control Tracking
Risk Assessment Dashboard
Premium Optimization Reporting
Claims Management Integration
Compliance Monitoring Alerts
Current Alliance Services Used:

Preferred Integration Timeline:

7. Risk Assessment & Claims History

Product Liability Claims (Last 5 Years):
Total Claims Paid:
Product Recalls (Last 10 Years):
Recall Costs Incurred:

Detailed Claims History:

Risk Mitigation Strategies Implemented:

Safety Training Program:
Employee Safety Record:

8. Additional Information & Special Considerations

Special Risk Factors (Check all that apply):

Products used in high-risk environments
Safety-critical component manufacturing
International distribution/export
Government/military contracts
Custom/one-off manufacturing

Additional Coverage Needs or Special Requirements:

Industry-Specific Compliance Requirements:

Application Review & Submission

Applicant Certification: I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation may void coverage and that this application does not bind coverage until formally accepted by the insurer.

Applicant Signature:

Authorized Representative Signature

Print Name:

Title:

Date:

Alliance for Contractors - Product Liability Insurance Services

Submit completed application to: [email protected]

Questions? Contact Alliance Insurance Services: (555) 123-4567