LSIRC Medical Product
Life Sciences Resource Center
The Experts in Life Science Insurance Specific Risk solutions for Life Science Organizations
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Quick Quote Premium Indication Form:

"Exclusive Life Sciences Insurance program reveals dangerous coverage gaps and could save you up to 27%!
Fill out the quick form below!"

*The information you provide on this form is for premium indications only. We respect your privacy and this information will not be shared with anyone outside the LSIRC and its affiliate insurance providers.

Applicant Information
Full name of entity to be named insured:
Principal Business Address:
City:
State: Zip
Contact Person:
Title:
Entity type:
Sic Code:
Years in business under current name:
Phone:
Fax:
Email:
Company/Product Website:
 
Policy Information
Insurance Requested: $ each occurrence
  $ aggregate
Present Insurance: $ each occurrence
  $ aggregate
Deductible / S.I.R.: $
Current Insurance Provider:
Has any insurer ever cancelled or refused to renew your product liability insurance? yes no
Renewal Date:
Retroactive Date:
Annual Premium:
   
Specified Products and Completed Operations
Product or Service #1: (or specific category)
Applicant acts as:
(press ctrl and click on selections for mulitple choices)
Number of Years:
Percentage of Gross Sales: %
Does applicant install/repair?
Product Sold to:
(press ctrl and click on selections for mulitple choices)
   
Product or Service #2: (or specific category)
Applicant acts as:
(press ctrl and click on selections for mulitple choices)
Number of Years:
Percentage of Gross Sales: %
Does applicant install/repair?
Product Sold to:
(press ctrl and click on selections for mulitple choices)
   
Product or Service #3: (or specific category)
Applicant acts as:
(press ctrl and click on selections for mulitple choices)
Number of Years:
Percentage of Gross Sales: %
Does applicant install/repair?
Product Sold to:
(press ctrl and click on selections for mulitple choices)
   
Have you discontinued or are you considering discontinuing any product to be covered by this insurance? yes no
Are any products known to be used with aircraft/missiles/aerospace? yes no
   
Sales and Marketing
Total sales or receipts: next year projected
  past 12 months
  1st prior year
  2nd prior year
Describe any significant change in product sales mix for next year's projection:
 
Do you wish to include customers as additional insureds with Vendor's coverage?
  yes no
   
Processing and Quality Control
Do others manufacture, assemble, package or install products sold under your name or label? yes no
Do you manufacture, assemble, 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 testing records kept?
Can you identify your products from competitors? yes no
Do your records show to whom and the date each product was sold? yes no
Do you require certificates evidencing Product Liability insurance from suppliers? yes no
   
Loss Prevention, Loss Control, Claim Defense
Who designs your products?
Are your designs reviewed, tested and verified by others? yes no
Do you maintain records of changes in designs, ads and sales brochures? yes no
If yes, how long? years
Are all instructions, operating manuals, ads, and warranties periodically reviewed by legal counsel? yes no
Are your products designed, tested labeled and manufactured to meet or exceed all applicable government and industry standards? yes no
Do you have a specific program to withdraw known or suspected defective products from the market? yes no
Have you ever recalled any known or suspected defective products from the market? yes no
Claims History
Total Losses, including deductible and/or defense costs. Please forward description of any losses over $10,000.
Claim Period #1
Years # of Claims Total Paid Amt. in Reserve Total Incurred Date of Loss
BI BI
    PD PD    

Claim Period #2
Years # of Claims Total Paid Amt. in Reserve Total Incurred Date of Loss
BI BI
    PD PD    

Claim Period #3
Years # of Claims Total Paid Amt. in Reserve Total Incurred Date of Loss
BI BI
    PD PD    

Are you aware of any other incidents, circumstances, defects, suspected defects or other sources that may result in claims against you? yes no

Additional Comments:
 

Thank you for your request, you should receive a response within two business days. If you have any questions, please contact at
1-866-710-3030 (toll free phone) or email shaunirwin@medicalproductinsurance.com

 

The Life Sciences Insurance
Resource
Center

A Division ofAnderson Insurance and Investment
Agency
312 Central Ave SE
Suite 392
Minneapolis, MN 55414

toll free phone (866)710-3030
toll free fax (866)810-3030