KAIGLER & COMPANY

Boat Builder Liability Application

You may fill out the following form online, or print it out and fax it to us at 615-376-0799.

ALL QUESTIONS MUST BE ANSWERED IN FULL - IF NOT APPLICABLE, SO STATE.

Effective Date:

1.  Name of Applicant (Include all subsidiary companies.) Please list any trade names. :

2.  Mailing Address:

Street:

City:

State:

Zip Code:

3.  (A) Limits Desired:

     (B) Deductible/Self-Insured Retention desired: $

4. (A) Applicant is: % Mfg.
% Distributor.
%Importer.
% Other (expain).

      (B) Applicant is: Individual Partership Corporation Other (explain)

5. How many years have you been in business under the present name?

(A) Have you ceased to manufacture any product during the past five years? yes no

If yes, attach (a) description, (b) sales and (c) losses by year.

(B) Have you or your principals ever engaged in this or similar enterprises under a different name?yes no

 If yes, attach full details.

6. (A) Location(s) at which you manufacture boats:

(B) Location(s) from which products/boats are distributed directly by you:

7. Furnish description of the manufacturing process.

8. Do you maintain and/or service the boats? yes no

If yes, attach full details including a copy of your standard written contract and receipts.

9. Do you maintain quality control procedures?yes no

 If yes, briefly outline of such procedures.

10. (A) Do you maintain complete inventory records reflecting shipments and/or delivery to consignees?yes no

(B) Are serial numbers and/or batch numbers shown on the finished boats? yes no

Are they shown on shipment invoices? yes no

(C) Can the date of manufacture of each boat be identified by the factory number stamped on it?

yes no

11. (A) Have you ever recalled boats for any reason?  yes no

If yes, attach details.

(B) Do you have a product recall plan? yes no

If yes, attach description.

(C) Do you have any new proposed products for introduction during the ensuing year? yes no

12. Has your product/boat ever been subjected to any inquiry by any Government Agency concerning the efficiency, adequacy of labeling, hazardous contents, or safety? yes no

If yes, attach full details and results of such inquiry.

13. Projected Estimate: Sales/Receipts $

No. of Units

Payroll $

14. Total sales or receipts for all products and services:

Past 12 mo. $

1st Prior Yr. $

2nd Prior Yr. $

No. of Units

No. of Units

No. of Units

15. Are all products designed by the applicant? yes no

If no please explain:

16. Do you issue guarantees and/or warranties to purchasers? yes no

If yes, for what period do you guarantee and/or warrant your products? (Attach full details and a copy of your form of guarantee and/or warranty.)

17. (A) Do you agree to hold dealers, distributors or suppliers harmless against claims or suits for Personal Injuries or Property Damage in connection with your products?   yes no

If yes, do you wish to add these vendors to your coverage as Additional Insured?yes no

If yes, please indicate either (1) All Vendors, or (2) Designated Vendors.

All Vendors Designated Vendors

If designated vendors, please attach list of said vendors and their corresponding sales.

18. Loss Experience (Summary): Provide hard copy loss data for the past five years.

Year

# Losses

Total Amount Paid & Res.

Carrier/Deductible


Year

#

$

Name/Amount:

Year

#

$

Name/Amount:

Year

#

$

Name/Amount:

19. Description of all losses over $10,000: Include Date of Loss, Amount Paid, Amount in Reserve, and Cause of the Accident and Dammages.

20. Are you aware of any incidents, not yet reserved, which could result in claims against you?

yes no

 If yes, attach details.

21. Has any insurance company or underwriter ever canceled or refused to renew your Products Liability Insurance? yes no

22. Engineering: In order that we may make a physical inspection of the applicant's premises, please provide:

Contact:

Title:

Phone:

23. Attach the following items:

  1. Financial Statement
  2. Original Brochures
  3. Sample Hold Harmless Agreements
  4. Hard Copy Loss Runs
  5. Supplemental Questionnaires - as required

24. Our engine purchases last year or estimated this year:

Outboards $

Inboards $

I/O $

Diesel $

25. The annual sales volume of   $

is distributed:

Domestic U.S.A. sales of     $

Foreign / export/ overseas in the amount    $

Mostly to the countries of:

Our product is built to the following standards:

Coast Guard

NMMA Certified

ABYC

ABS

Other

(explain)

This Application Submitted By:

Name:

Company:

Address:

Street:

City:

State:

Zip Code:

Phone:

Fax:

E-mail (required):


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