Business Address*
About Your Organization Is the business incorporated?* Do you expect any significant changes to your operations within the next 12 months?* Please provide details
Examples: New products, New services Expansion, New locations, Acquisitions
Have you ever operated under another business name?* Previous business name(s)
Have you acquired any businesses, subsidiaries, or related entities within the past 5 years?* Have you filed for bankruptcy or insolvency protection within the past 10 years?* Has the company, or any owner, officer, director, partner, or shareholder, been investigated for alleged criminal activity related to the business? Please list any additional locations not noted above Subsidiaries or Related Companies Please describe your business operations.
Examples: Manufacturing, Distribution, Research & Development, Product Design, Consulting, Contract Manufacturing, Clinical Services
Revenue Please provide your gross revenue by activity.
Manufacturing and Sale of Own Products
Contract Manufacturing of Own Products
Contract Manufacturing for Third Parties
Wholesale / Distribution of Third-Party Products
Repackaging / Relabelling
Retail Sales
Licensing Agreements / Royalties
Research & Development
Consulting Services
Other
Please provide your gross revenue by geographic region.
Canada
United States
All Other Countries
Please list any countries outside Canada and the United States where your products are sold or revenue is generated.
Products Top Selling Products Medical Device Classification
Please indicate the approximate percentage (%) of revenue generated by each device class.
Medical Device Categories
Please indicate the approximate percentage (%) of revenue generated by each device type.
Have any products been on the market for less than 3 years?* Have any products been recalled or withdrawn within the past 5 years?* Have any adverse event reports been filed involving your products within the past 5 years?* Are any products sold under a third-party brand or incorporated into another company's product?* Are all products approved by the applicable regulatory authorities? Do you expect to launch any new products within the next 12 months?* Do you provide clinical services as part of your operations?* Do employees interact directly with patients, consumers, or end users?*
Requested Insurance Coverage
1. Commercial General Liability & Product Liability* Provides coverage for eligible claims alleging bodily injury or property damage arising from your business operations and products, subject to the policy’s terms, conditions, and exclusions.
2. Errors & Omissions / Professional Liability* Provides protection for claims alleging financial loss resulting from professional services, advice, research, consulting, testing, design, or other professional activities performed by your organization. Coverage is subject to policy terms, conditions, exclusions, and any retroactive date requirements.
3. Medical Malpractice / Professional Healthcare Liability* May provide protection for claims arising from healthcare, clinical, medical, scientific, laboratory, or related professional services provided by qualified personnel. Coverage availability depends on the nature of services provided and underwriting approval.
4. Clinical Trials Liability (Optional) May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions.
5. Product Recall Expense (Optional) 6. Cyber Liability (Optional) May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions.
7. Property Insurance (Optional) 8. Equipment Breakdown (Optional) 9. Crime Coverage (Optional) 10. Directors & Officers Liability (Optional) May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions. May provide protection for claims arising from approved clinical trial activities involving study participants. Coverage is subject to underwriting review, study protocols, jurisdictional requirements, and policy terms and conditions.
11. Environmental / Pollution Liability (Optional) May provide protection for certain liabilities arising from pollution conditions, contamination events, cleanup costs, or environmental damage where coverage is specifically provided under the policy. Coverage is subject to underwriting review and policy wording. May provide protection for certain liabilities arising from pollution conditions, contamination events, cleanup costs, or environmental damage where coverage is specifically provided under the policy. Coverage is subject to underwriting review and policy wording.
Additional Coverage Information
For any coverage requested above, please indicate any desired deductible(s), retroactive date(s), aggregate limit(s), or other coverage requirements not already specified.
If requesting a claims-made coverage (such as Errors & Omissions, Medical Malpractice, Clinical Trials Liability, Cyber Liability, Directors & Officers Liability, Environmental Liability, or similar), please indicate the current retroactive date, if known:
Have these coverages been maintained continuously from the retroactive date(s) indicated above? 