Product Liability | Proposal

Personal Details

Risk Details 1

Risk Details 2

General Policy Details

Personal Details

Proposer Type

Bank Assurance Officer

Select Intermediary branch

Insurance Company

ID Type

ID Number

KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which FBBI branch do you want to be served from?

Do you have a Public Liability from FBIA?

Period of Insurance

Insurance Start Date

Insurance End Date

Building Infomation

Name of Building

Location (L.R.Number)

Use of Building

Street/Road

Area/Estate

Town Code

Earth Quake Zone

Business/Trade/Occupation

Explain What Your Business Entails

Please Specify Any Other Business Entails.

Give details of products subdivided into different categories (range) if more than one type of product is Involved

Describe the purpose or use of the product (s) 1

Product Name

Describe Purpose

Use as Component

What type of products and by which industry?

Assembled by another firm(or person)

Give Details?

File Upload

Note:- Brochures or leaflets describing the products can be enclosed if available.

Browse

* Allowed file formats (xls, xlsx, pdf, jpg, jpeg, doc, txt, docx, png)

If you incorporate parts manufactured elsewhere for any of the above listed products, wholly or partly, including raw materials, state the part or component and from where they are sourced

Are any of your products sourced locally or abroad?

If so, Please give details

Are any of your Products Exported ?

Note: This cover excludes exports to the USA and Canada.

Country Details 1

Country

Estimated turnover

Are any of the products supplied for use in connection with:

Aircraft, aerospace equipment or aerial devices of any kind?

Pharmaceuticals?

Offshore Platform and Rigs?

Since when have you been engaged in manufacturing/supplying these products?

Do you enter into any agreement or undertaking to indemnify or compensate suppliers of materials or components or subcontractors or processors in respect of any injury or damage?

What type of packaging do you use?

Do you manufacture the packaging materials?

where are the packaging/containers acquired?

Do you give any written guarantee or conditions of sale with or in respect of any of your products by

By printing on the package /product

By a separate leaflet or brochure?

please supply sample wordings

Are there any quality control measures in place with regard to the product?

please explain

Are there any Statutes, Laws or Bylaws that govern your operations with regard to the product proposed for insurance?

Statutes, Laws or Bylaws Details 1

Law

Name, Title or Heading of Law

Do you operate in compliance with this Laws?

Please Specify

Limits of liability required:

All claims arising during the Period of Insurance

Estimated Annual Turnover

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 5 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION | Please Read Carefully *

I/ We do hereby declare that the above answers and statements are true and that I/ We have withheld no material information regarding this proposal. I/ We agree that this declaration and the answers given above as well as any proposal or declaration or statement made in writing by me/ us or anyone acting on my/ our behalf shall form the basis of the contract between me/ us and the Company. I/ We further agree to accept indemnity subject to the conditions in and endorsed on the Company’s policy.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Family Bank Insurance Agency to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Product Liability Proposal

Personal Details

Contact Details

Period of Insurance

Building Infomation

Describe the purpose or use of the product (s) 1

File Upload

Note:- Brochures or leaflets describing the products can be enclosed if available.

Note: This cover excludes exports to the USA and Canada.

Country Details 1

Are any of the products supplied for use in connection with:

Statutes, Laws or Bylaws Details 1

Limits of liability required:

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *