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AncoTek Program

Commercial General Liability Application
Including Products and Completed Operations

Applicant Instructions

  1. Answer all questions. (If the answer to any question is NONE or NOT APPLICABLE, please state NONE or N/A.)
  2. Read CAREFULLY the statements at the end of this application.

Please Note: It is highly recommended that you read and/or print this form in its entirety and gather materials or information for your responses prior to filling out the form online. Any information you input will be lost if you close your browser or navigate to another page or website prior to submitting your information by pressing the "Submit" button at the bottom of this form.

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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

Available in Texas and all states except NY, WA, HI, VT and AK.

Applicant
Full name or all entities to be named insureds: 
Principal Address: 
City:  State: Zip:
Contact Person: 
Phone #:  Fax #:
Email Address: 
Business Type:   
Years in business:  (under present name)
Describe present or prior affiliation with other firms:
Proposed Effective Date:  (for this insurance)
Estimated receipts for the new policy year
(medical equipment only):
Sales Receipts:  $
Service/Repair Payroll:  $
Please list sales/service amts for any non-medical equipment:
Sales: $   Service: $

 

Your Operation
Type of Equipment Sold or Serviced
Please give a description of your operations:
Have you discontinued or are you considering discontinuing any product to be covered by this insurance?:  Y N
If "Yes", please explain fully:

Do you import component parts?:  Y N
Do you export products or have foreign operations?:  Y N
Are any of your products or services known to be used in connection w/ aircraft/missiles/aerospace?:  Y N
Are any of your products or services subject to registration/regulation/review by any gov't agency?: Y N
Please explain any "Yes" answers above:

 

Claim's History
5 Years or More
Describe in detail any claims you have had.
Include details as to date, circumstances, amounts, etc.:

 

Sales & Marketing
Do you anticipate any changes in products or services offered?:  Y N
If "Yes", please describe in detail:

Are you required to have coverage for "additional insureds"?:  Y N
Do you manufacture, assemble, or package products?:  Y N
If "Yes", please describe in detail:

Do others manufacture, assemble, package or install under your name or label?:  Y N

 

Miscellaneous
Who is your present insurer?:
Has any insurer ever cancelled, restricted or refused to renew your products liability insurance?:  Y N
If "Yes", please explain in detail:

 

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional
information where there was not enough fields above, please enter them here:

 

DISCLAIMER
Submitting this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but a copy of this submission will be attached to the policy, if issued.

Please click on the "Submit Form" button to send your request.
One of our representatives will respond to your submission as soon as possible.

   

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800-749-1733