1. Name and Address of Applicant:

(please attach list of subsidiaries, if applicable under this policy)

Street Address:

City: State: ZIP Code:
2. Main Contact Name: Main Contact Phone:
3. Website: E-mail:
4. Date first established:
5. Prior Experience in this business under any other name:   Yes   No
If yes, please provide name of business:
6. Type of Operations:   Manufacturer   Importer   Wholesaler   Distributor
     Exporter    Retailer    Other


Type of Products:

8.  Total Number of Plants/Facilities:

Home Country =  


9.  Total Number of Employees:

Home Country =  



10. Please list the sales figures for the upcoming year, the current year, and the prior 3 years and indicate the approximate percentage of sales per country:

Year Total Sales   USA (%)   Canada (%)   Europe (%)   Other (%)


11. Please complete the following information for the top 3 plants / facilities:

Address   Total Sales   Products   Production Lines   Daily output in $
Product I        
Product II        
Product III        


12. Please comment on any spare production line or capacity as it relates to the top 3 plants /facilities listed above:


13. Please complete the following information for the top 3 products or if coverage is contract specific, please list products to which this insurance is to apply:

Product Name/ Type   Total Sales   Average batch size in $   Largest batch size in $   Daily output in $
Product I        

Product II


Product III



14. Is coverage Contract or Product Specific?   Yes   No

(If yes, please provide a copy of the contract)


15. Please list your top 5 customers by percentage of sales. Please classify the customer (wholesale, retail, manufacturing, broker or other):


% of Applicants Sales

Type of Customer


16. Please list the estimated total sales (in percentage) by:

Wholesale Retail Manufacturing Broker Other


17. Please provide percentage of branded (product manufactured for others with their name), non-branded (products with no name) and/or own label products (with applicants name or brand):

Branded Non-Branded Own Label


18. What percentages of your products are manufactured by outside vendors?


19. Please advise how products are packed and whether packing is done in house or by 3rd party.

Product Type of Packaging

In-House  or 3rd Party


20. What is the average useful life of your products (as a percentage of total sales)?

a.  One week to one month:

b.  One month to six months:

c.  Six months to a year:

d.  More than 1 year:


21. Do products require the following:

External power source to operate?   Yes   No

Special storage facilities?   Yes   No



22. Please indicate any new products that have commenced production or have entered the public stream of commerce within the last 12 month:



23. Please indicate the estimated number of buyers:


24. Please indicate the average length of contractual relationship with key buyers:


25. Please indicate how many of your buyers are domestic and how many are foreign:
  Domestic =      Foreign =  


26. Please complete in respect of your top 5 suppliers and then all other, per below:

Buyers Name

Domestic or


% component of product?


27. Do you require buyers to abide by specified standards?   Yes   No

28. Do you have a Vendor Approval Program in place?   Yes   No

29. Do you audit your third party suppliers?   Yes   No

(if yes, please provide copies of last audits for top 5 suppliers)

30. Do you have contracts in place with all of your buyers?   Yes   No


31. Do you have a Quality Assurance Plan in place? (if yes, please provide copy)   Yes   No

32. GMPs (Good Manufacturing Practices) in place? (please provide copy)   Yes   No

33. Do you have Six Sigma protocols in place? (please provide copy)   Yes   No

34. Is there a Quality Assurance Department?   Yes   No

35. Do you have a testing program at critical control points on the following:

i. Incoming material (incl. packaging and labels)    Yes    No

ii. Manufacturing / Processing    Yes    No

iii. End product (incl. packaging and labels)   Yes    No

36. Do you have procedures for new product validation?   Yes   No

37. Do you use internal and/or external testing laboratory?   Internal     External

38. Are labels inspected?   Yes   No

39. Do warning labels meet applicable industry standards?   Yes   No

40. Are audits performed by an accredited third party?   Yes   No

41. Do all of your products comply with all US / Europe regulations and / or local law in the country where sold?   Yes   No


I declare that the statements and particulars in this application are true and that no material facts have been misstated or suppressed after enquiry. I agree that this application, together with any other information supplied shall form the basis of any contract affected thereon..

Signature:    Date: