The Beauty Products Insurance Program Application

 
Veracity Insurance Solutions, Inc.
260 South 2500 West, Suite 303
Pleasant Grove, UT 84062
Toll Free 866-395-1308
Direct 801-216-8251
Fax 801-763-1374

Supplemental Application for the Natural Perfumers Guild

Instructions:

Answer all questions. If the answer is NONE, please state "NONE." Application must be signed and dated by an officer of the company.

Please fill out

A. Applicant

1. Company/Insured Name:
2. Contact Name: E-mail Address:
3. Principal Address:
4. Mailing Address:
5. Phone #: Fax #: Website:
6. Date Business Started:
7. Form of Business:
         
8. Agent Name: Agent E-mail Address:
9. Agent Phone #:

B. Product and Sales Data

1. For principal product or service, indicate:

Descriptions of Major Products # of Units Sold PRINCIPAL END Usage Manufacture orDistribute % OF GROSS ANNUAL SALES

2. Historical Exposure Base Informaion (Minimum 3 years required if applicable):

Year Domestic Sales Foreign Sales Total Sales Other Data
Projected
Expiring
1st Prior
2nd Prior
3rd Prior

3. Loss History:

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?    

If YES, we will follow up with you and request loss runs.

C. Manufacturing / Distribution

Yes

No
1. Are all the products sold considered "Generally Regarded As Safe" by the FDA?
2. Do you import any products from Asia, Africa, or South America? If "yes", please fill out the list of countries:
3. Do you export products or have foreign operations? If "yes", please fill out the list of countries:
4. Do you make or sell any of the following products:
  • Drugs, Vitamins or Nutraceuticals
  • Acetone Based Products
  • Aerosol Products
  • Invasive Body Inks
5. Do you make or handle any product that is explosive, flammable or poisonous either by itself or in combination with other materials?
6. Could any of your products be classified as pharmaceuticals?
7. Are any of your products sold under another's name or label? If "yes", fill out the details:
8. Do you sell or make any of the following cosmetic products:
  • Lipstick
  • Perfumes
  • Blushes
  • Mascara
  • Facial Foundations
  • Eyeliners
  • Makeup Removers
9. If yes, are the products considered 100% natural or organic?
10. What percentage of your total sales are directed towards infant/juvenile products?

D. Marketing

1. Percentage of total sales to:
2. Suppliers and distributors of your products:

Yes

No
  a. Do you hold them harmless or insure them?
  b. Do they hold you harmless or insure you?

E. Loss Prevention

Yes

No
1. Have your products ever been subject to injury or investigation relative to product safety by any governmental agency? If "yes", attach details.
2. Do you have a written products recall plan? If "yes", please attach.
3. Have you ever recalled products because of a potential product safety hazard?
 
  • If yes, indicate percent of recovery:
  • %
4. Do you have a written products safety program for which specific individuals have responsibility for implementation? If "yes" attach copy or outline.

F. Product Design

Yes

No
1. Do you do your own formulating and design your work?
2. Do you maintain records of design changes and reasons justifying these changes?
3. Are your designs subject to independent external review, testing or certification? If "yes" attach details and dates.
4. Are your products designed, tested, labeled and manufactured to meet or exceed all government and industry standards?

G. Quality Control and Testing

Yes

No
1. Are warranties obtained from all suppliers?
2. Are quality control records kept so that you can identify at a later date what tests you applied to a given product at a given time?

H. Instructions/Warnings/Advertising/Warranties

Yes

No
1. Do warning labels comply with federal statutory warning labeling requirements?
2. Does all product labeling comply with FDA guidelines?
3. Do you expressly disclaim or limit warranties for your products?
4. Do you provide any specific training or instruction for the ultimate user, in the proper use of your product?

I. Loss Control and Defense

Yes

No
1. Can you determine, based on available records, for all products you have sold:    
  a. when any given product was manufactured?
  b. to whom it was sold, and the date of sale?
  c. who supplied parts and supplies going into the final product?
2. Do you maintain copies of old instruction or operation manuals and advertising material?

J. Accident procedure:

Yes

No
1. Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your products?
2. Does your procedure provide for examining and preserving any allegedly defective product, with the results of such examination recorded?

Property Coverage



Choose Limit  
 
 
 
 

Warranty

NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.

CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied).

IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.
Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, partners, directors, officers and employees.
Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective date).

Name of applicant: Date:

Title: (owner, partner, officer)
Comments: