Manufacturing & Wholesale Application "*" indicates required fields Named Insured*Business Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Contact*Email* Phone*About Your OrganizationWhat year was your organization established*Is your organization incorporated? Yes No Do you expect a material change in your operations in the next 12 months?* Yes No Please provide detailsExamples: New products, New services, Expansion, New, locations Acquisitions Have you operated under another name?* Yes No Please provide detailsHave you acquired any subsidiaries in the past 5 years?* Yes No Please provide detailsHave you filed for bankruptcy in the past 10 years?* Yes No Please provide detailsHas the company, or any owner, officer, director or partner, been investigated for alleged criminal activity related to the business? Yes No Please provide detailsPlease list any additional locations not noted aboveStreet AddressCityProvincePostal Code Add RemovePlease list any of your subsidiaries or related entities that are controlled by or control your organizationEntity NameDescription of OperationsRelationship to Named Insured Add RemovePlease describe all of your operationsRevenue Please indicate your gross revenue by the following breakdown: Revenue Source Previous 12 Months Next 12 Months Canada U.S.A. Rest ofWorld Canada U.S.A. Rest ofWorld Contract Manufacturing for Third PartiesPrevious Contract Manufacturing for Third Parties CanadaPrevious Contract Manufacturing for Third Parties U.S.A.Previous Contract Manufacturing for Third Parties Rest of WorldForecasted Contract Manufacturing for Third Parties CanadaForecasted Contract Manufacturing for Third Parties U.S.A.Forecasted Contract Manufacturing for Third Parties Rest of WorldInstallation and/or Repair ServicesPrevious Installation and/or Repair Services CanadaPrevious Installation and/or Repair Services U.S.A.Previous Installation and/or Repair Services Rest of WorldForecasted Installation and/or Repair Services CanadaForecasted Installation and/or Repair Services U.S.A.Forecasted Installation and/or Repair Services U.S.A.Manufacturing and Sale of Own ProductPrevious Manufacturing and Sale of Own Product CanadaPrevious Manufacturing and Sale of Own Product U.S.A.Previous Manufacturing and Sale of Own Product Rest of WorldForecasted Manufacturing and Sale of Own Product CanadaForecasted Manufacturing and Sale of Own Product U.S.A.Forecasted Manufacturing and Sale of Own Product Rest of WorldManufacturing is Contracted Out for Own ProductPrevious Manufacturing is Contracted Out for Own Product CanadaPrevious Manufacturing is Contracted Out for Own Product U.S.A.Previous Manufacturing is Contracted Out for Own Product Rest of WorldForecasted Manufacturing is Contracted Out for Own Product CanadaForecasted Manufacturing is Contracted Out for Own Product U.S.A.Forecasted Manufacturing is Contracted Out for Own Product Rest of WorldRepackaging or Relabelling of Wholesale ProductsPrevious Repackaging or Relabelling of Wholesale Products CanadaPrevious Repackaging or Relabelling of Wholesale Products U.S.A.Previous Repackaging or Relabelling of Wholesale Products Rest of WorldForecasted Repackaging or Relabelling of Wholesale Products U.S.A.Forecasted Repackaging or Relabelling of Wholesale Products U.S.A.Forecasted Repackaging or Relabelling of Wholesale Products U.S.A.Retail Sales / Direct Sales to ConsumerPrevious Retail Sales / Direct Sales to Consumer CanadaPrevious Retail Sales / Direct Sales to Consumer U.S.A.Previous Retail Sales / Direct Sales to Consumer Rest of WorldForecasted Retail Sales / Direct Sales to Consumer CanadaForecasted Retail Sales / Direct Sales to Consumer U.S.A.Forecasted Retail Sales / Direct Sales to Consumer Rest of WorldWholesale/Distribution of Third Party’s ProductsPrevious Wholesale/Distribution of Third Party’s Products CanadaPrevious Wholesale/Distribution of Third Party’s Products U.S.A.Previous Wholesale/Distribution of Third Party’s Products Rest of WorldForecasted Wholesale/Distribution of Third Party’s Products CanadaForecasted Wholesale/Distribution of Third Party’s Products U.S.A.Forecasted Wholesale/Distribution of Third Party’s Products Rest of WorldOther:Previous Other CanadaPrevious Other U.S.A.Previous Other Rest of WorldForecasted Other CanadaForecasted Other U.S.A.Forecasted Other Rest of WorldPlease indicate the countries outside of Canada and the United States of America where you have sales/revenuesHazardous MaterialsDo you store hazardous materials at your premises?* Yes No Please provide detailsDo you store and dispose of all hazardous materials in compliance with federal and provincial laws and regulations? Yes No Do you have any personal property of others in your care, custody or control?* Yes No Please provide detailsYour ProductsPlease list your 10 top-selling products by approximate percentage (%) of gross revenue % Your Product Product 1 %Please enter a number less than or equal to 100.Product 1 nameProduct 2 %Please enter a number less than or equal to 100.Product 2 nameProduct 3 %Please enter a number less than or equal to 100.Product 3 nameProduct 4 %Please enter a number less than or equal to 100.Product 4 nameProduct 5 %Please enter a number less than or equal to 100.Product 5 nameProduct 6 %Please enter a number less than or equal to 100.Product 6 nameProduct 7 %Please enter a number less than or equal to 100.Product 7 nameProduct 8 %Please enter a number less than or equal to 100.Product 8 nameProduct 9 %Please enter a number less than or equal to 100.Product 9 nameProduct 10 %Please enter a number less than or equal to 100.Product 10 nameHave any of your products been on the market for less than 3 years?* Yes No Please provide detailsHave any of your products been recalled or withdrawn in the past 5 years?* Yes No Please provide detailsAre any of your products sold under third-party labels or as a component(s) of others’ products?* yes No Please provide detailsDo you intend to bring any new product(s) to market in the next 12 months?* Yes No Please provide detailsCan any of your products or services be used in or in connection with automotive, aircraft, aerospace,military and/or watercraft?* Yes No Please provide detailsAre you in compliance with all applicable regulatory guidelines and applicable standards? CSA, ULC, WCB, etc Yes No Have you been cited for any regulatory violations in the past 5 years?* Yes No Please provide detailsIf applicable, do you follow Good Manufacturing Practices (GMP)? Yes No Are you ISO registered?* Yes No Please provide ISO numberDo you have a formal Product Recall Procedure in place? Yes No Do you have a formal written Quality Control and/or Quality Assurance program(s) in place? Yes No Do you conduct regular batch testing? Yes No Do you maintain all rights of recourse against your suppliers and/or product manufacturers? Yes No Do you have a Risk Management and Loss Prevention Program in place? Yes No Do you obtain a certificate of insurance from all suppliers and contractors? Yes No Are all contracts reviewed by Legal or your legal representative? Yes No Do you review all policies and procedures on a regular and ongoing basis? Yes No Contract Manufacturing Do you always use standard contracts prior to providing services (including change orders)? No Yes What is the average dollar value of your contracts?What is the average duration of your contracts?What is the total number of your current contracts?Have any of your clients ceased payment or requested a refund of fees in the past 3 years?* Yes No Please provide detailsPlease indicate your largest 3 contracts for the current year:Type of CustomerContract ValueServices Provided Add RemoveClaims History Have you ever had a claim against your organisation’s insurance policies?* Yes No Please provide details including date of loss, amount paid or held in reserve, and description of allegation.Are you aware of any incidents or circumstances that could potentially give rise to a claim?* Yes No Please provide detailsRequested Insurance Coverage 1. Commercial General Liability & Product Liability* $2M $5M $10M More Provides coverage for eligible claims alleging bodily injury or property damage arising from your business operations and products, subject to the policy’s terms, conditions, and exclusions.2. Errors & Omissions / Professional Liability* $2M $5M $10M More Provides protection for claims alleging financial loss resulting from professional services, advice, research, consulting, testing, design, or other professional activities performed by your organization. Coverage is subject to policy terms, conditions, exclusions, and any retroactive date requirements.3. Medical Malpractice / Professional Healthcare Liability* $2M $5M $10M More May provide protection for claims arising from healthcare, clinical, medical, scientific, laboratory, or related professional services provided by qualified personnel. Coverage availability depends on the nature of services provided and underwriting approval.4. Clinical Trials Liability (Optional) Not Required May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. $2M $5M $10M More May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. 5. Product Recall Expense (Optional) Not Required Enter Coverage Amount Required ($)May help reimburse certain expenses associated with the withdrawal, recall, replacement, inspection, communication, or disposal of products when a covered recall event occurs. Coverage varies significantly by insurer and policy wording 6. Cyber Liability (Optional) Not Required May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. $2M $5M $10M More May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. 7. Property Insurance (Optional) Not Required Property Insurance Limit Requested: $May provide coverage for buildings, tenant improvements, equipment, inventory, laboratory contents, and other insured property against specified causes of loss. Coverage is subject to policy terms, valuation provisions, exclusions, and deductibles. 8. Equipment Breakdown (Optional) Not Required Limit Requested: $May provide coverage for sudden and accidental mechanical or electrical breakdown of eligible equipment, including certain laboratory, manufacturing, refrigeration, and production equipment. Coverage is subject to policy conditions and exclusions. 9. Crime Coverage (Optional) Not Required Limit Requested: $May provide protection for certain losses resulting from employee dishonesty, theft, fraud, forgery, funds transfer fraud, or other covered criminal acts. Coverage varies by policy and insurer. 10. Directors & Officers Liability (Optional) Not Required May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. $2M $5M $10M More May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. 11. Environmental / Pollution Liability (Optional) Not Required May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. $2M $5M $10M More May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. Additional Coverage Information For any coverage requested above, please indicate any desired deductible(s), retroactive date(s), aggregate limit(s), or other coverage requirements not already specified.If requesting a claims-made coverage (such as Errors & Omissions, Medical Malpractice, Clinical Trials Liability, Cyber Liability, Directors & Officers Liability, Environmental Liability, or similar), please indicate the current retroactive date, if known: Retroactive Date(s): Have these coverages been maintained continuously from the retroactive date(s) indicated above? Yes No Please provide details
