Nutra Sure Quote Nutra Sure Quote Company InformationContact Person* First Last Business NameEntity TypeIndividualLimited Liability Corp.PartnershipCorporationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Current Insurance Co.*Current Premium Payment*Payment Frequency*Mo.Qtr.HalfYearGross Revenue*ProductsM: manufacturer W: wholesaler R: retailer I: importer MR: manufacturer's rep. C: consumer direct O: otherProducts and Services (or specified categories)Applicant Acts as a(n)ManufacturerWholesalerRetailerImporterManufacturers Rep.No. Years% of Gross ReceiptsProducts Sold to:WholesalersRetailersConsumers DirectOtherProducts and Services (or specified categories)Applicant Acts as a(n)ManufacturerWholesalerRetailerImporterManufacturer Rep.No. Years% of Gross RecieptsProducts Sold to:WholesalerRetailerConsumer DirectOtherProducts and Services (or specified categories)Applicant Acts as a(n)ManufacturerWholesalerRetailerImporterManufacturer Rep.No. Years% of Gross RecieptsProducts Sold to:WholesalerRetailerConsumer DirectOtherEstimated annual gross receipts for the coming yearAnnual gross receipts last 12 monthsAnnual gross receipts 1st prior yearIs the Applicant presently considering any change in the mix of products including any new products or services for the coming year?YesNoHas the Applicant discontinued or is it considering discontinuing any product or service listed above?YesNoPROCESSINGDo products and/or components thereof, originate from outside of the United States?YesNoIf Yes, specify the country of origin:The name of each organization manufacturer, distributer or supplierDo others manufacture or package products under the Applicant's name or label?YesNoIf Yes, provide the name(s) of contract manufacturer(s)Does the Applicant manufacture or package products for others under their name or label?YesNoIf Yes, explainQUALITY CONTROL AND RECORDKEEPINGDoes the Applicant have a quality control and testing procedure?YesNoIf Yes, how long does the Applicant keep quality control and testing records?Can the Applicant identify its product(s) from those of competitors?YesNoDo all records show to whom and the date each product was sold?YesNoDoes the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?YesNoWho designs Applicant's products?Are product designs reviewed, tested and verified by others?YesNoDoes the Applicant have a specific program to withdrawn known or suspected defective products from the market?YesNoHas the Applicant ever recalled or is it considering recalling any product?YesNoHave any of the Applicants' products or ingredients or components thereof, ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any governmental, quasi-governmental, administrative, regulatory or oversight body?YesNoInsurance InformationLimits of Liability requestedIndicate the deductible requested**The company does not guarantee to offer any of the above limits and/or deductables.Has any insurer declined, canceled, or non-renewed any Product Liability Insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?YesNoIf Yes, provide detailsHas any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last five (5) years?YesNoIf Yes, be prepared to provide five (5) year loss history for all claims, including any predecessor. A description of any loss greater than $10,000 will be required.Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, condition, defect or suspected defect which may result in a Products Liability claim?