DistributorsandWholesalersProgramGeneralLiability.docVIP

GLS-APP-76s (3-12) Page  PAGE 3 of  NUMPAGES 3  FORMCHECKBOX
 Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258  FORMCHECKBOX
 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258  FORMCHECKBOX
 Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 ? Fax (480) 483-6752 Distributors and Wholesalers Program General Liability Supplemental Application (Complete in addition to ACORD General Liability Application) Name of Applicant:  FORMTEXT
????? Web site Address:  FORMTEXT
????? Location Address:  FORMTEXT
????? ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” 1. Provide detailed description of the products the applicant distributes:  FORMTEXT
?????2. Does the product manufacturer(s) have a Web site?  FORMCHECKBOX
 Yes  FORMCHECKBOX
 No If yes, provide Web site address(es):  FORMTEXT
?????3. Does applicant verify the manufacturers have products liability coverage?  FORMCHECKBOX
 Yes  FORMCHECKBOX
 No 4. Is applicant named as additional insured by the manufacturer(s)?  FORMCHECKBOX
 Yes  FORMCHECKBOX
 No 5. Who are the applicants primary customers?  FORMTEXT
????? 6. What percent of sales are retail?  FORMTEXT
???% 7. What percent of sales are via the internet? Retail  FORMTEXT
???% Wholesale  FORMTEXT
???% 8. Does applicant import directly from foreign countries?  FORMCHECKBOX
 Yes  FORMCHECKBOX
 No 9. Does applicant manufacture or assemble any products?  FORMCHECKBOX
 Yes  FORMCHECKBOX
 No 10. Is applicant a manufacturer’s representative for any products sold or distributed?  FORMCHECKBOX
 Yes  FORMCHECKBOX
 No 11. Does applicant do any relabeling, repackaging, m