CBD/Hemp - Ingestible Insurance Application

Section 1: Insured Information

Full Name:

Company Name:

Mailing Address:

City:

State:

Zip:

Mobile Phone:

Email:

Website:

Business Type:

Other business type

Section 2: Specified Products and Completed Operations

Provide the following information for those products and/or services you want coverage for. Only those products and services listed below will be considered for coverage.

Total gross receipts from all products and services listed above:

Estimated annual gross receipts for the coming year ($):

Annual gross receipts: Last 12 Months ($):

Are you presently considering any change in the mix of products, including adding new products or services for the coming year?

Yes

If yes, please provide details:

Section 3: Processing and Quality Control

Do any products, ingredients, or components thereof originate from outside of the United States?

Yes

Countries of Origin:

Name of each organization manufacturer, distributor, or supplier:

Please provide the name(s) and address(es) of the company that manufactures your products:

Do you manufacture or package products for others under their name or label?

Yes

If yes, what percentage of sales are from contract manufacturing?

Do you have a quality control and testing procedure?

Yes

If yes, how long do you keep quality control and testing records?

Do any products contain steroids or steroid-like substances, or claim to increase testosterone?

Yes

If yes, please provide details:

Do you promote any of your herbal products for child use?

Yes

Do you have a specific program to withdraw known or suspected defective products from the market?

Yes

Have you ever recalled or are you considering recalling any product?

Yes

If yes, please explain:

Have any of your products, 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?

Yes

If yes, please provide details:

Are business operations operated out of a personal residence?

Yes

Section 4: Insurance Information

Is the product currently insured?

Yes

Insurance Company

Limits of Liability

Deductible/SIR

Premium

Expiration Date

Retroactive/ Prior Acts Date

Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last 5 years?

Yes

If yes, provide 5 year loss history for all claims, including any predecessor.

Attach a description of any loss greater than $5,000.

Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, defect, or suspected defect that may result in a Products Liability claim?

Yes

If yes, please provide details:

Section 5: Excluded Products/Ingredients

Do you have any past, present, or planned association with any of the following Ingredients?

Yes

If Yes, please list all of your products that include any of these ingredients; attach product labels for each one and total projected sales for each of these products.

Product Labels:

It is agreed there is no coverage afforded under this certificate for the following product(s): Derivatives, related botanicals, and/or extracts whether as a primary ingredient or in combination with other ingredients.

1. anabolic-androgenic steroids;
2. anabolic steroids;
3. androstenedione;
4. aristolochic acid;
5. chaparral;
6. comfrey (pyrrolizidine alkaloids)
7. DMAA, 1,3- Dimethylamylamine, Dimethylamylamine, Methylhexanamine
8. ephedra, mahuang and psuedoephedrine
9. ephedra/ephedrine alkaloids
10. Fenfluramine;
11. GB; 1, 4 butanediol
12. GHB, GHV (Y-hydroxybutyric acid)
13. GVL (gamma-valerolactone)
14. Glibenclamide, Glyburide, Liqiang 4

15. KAVA,AVA, KAVA-KAVA and related derivatives
16. Lobelia
17. Pennyroyal oil
18. Picmalion
19. stephania or any adulterated botanicals
20. yohimbe
21. AMP Citrate, 1,3-dimethylbutylamine citrate, 1,3-dimethylbutylamine HCL, methylpentanamine
22. Dendrobium
23. BMPEA, BMethylphenethylamine, Acacia Rigidula
24. Vinpocetine
25. Any product, supplement or additive determined by the United States Food and Drug Administration at any time to be a “Class I Health Hazard”. Class I. Health Hazard means a product presenting a reasonable probability that the use of or exposure to it will cause serious adverse health consequences or death

PLEASE CONFIRM THAT YOU HAVE READ AND UNDERSTAND THE PRODUCTS LISTED ABOVE ARE EXCLUDED. PLEASE PUT REQUIRED INITIALS HERE:

INITIALS:

Product labels and ingredients are required to purchase this insurance. Did you provide a website URL in section 1 which includes this information?

Yes

Please provide product labels and ingredient lists, brochures, and instructions.

I agree to the Terms & Conditions.