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Vitamins, Supplements & Nutraceuticals Insurance Application

Vitamins, Supplements & Nutraceuticals Insurance Application

Company Details

Company:

Entity Type:

Contact Name:

Mailing Address:

City:

State:

Zip:

Mobile Phone:

Email:

Website:

Is your Physical Address the same as your Mailling Address?

Yes

Business Street Address:

City:

State:

Zip:

Is your business domiciled in the United States?

Yes

Business Activities

Please select the business activities involved with this business.

Basic Vitamins & Supplements

Workout/Bodybuilding Supplement Products

Sexual Enhancement Products

Energy Drinks

CBD Products

Apparel

Other

Define other:

Are your CBD products:

Ingestible

Topical

Are you a distiller, extractor, processor, or grower of CBD/Hemp?

Yes

Is any CBD/hemp imported from outside North America?

Yes

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

Estimated annual CBD sales for the coming year ($):

Manufacturing and Quality Control

Do you manufacture your products yourself?

Yes

Please provide the name(s) and address(es) of contract manufacturer(s):

Do you comply with Good Manufacturing Practices (GMP)?

Yes

Are any products, ingredients, or components thereof manufactured out of a residence?

Yes

Are your products tested by a third party lab?

Yes

Do you do any contract manufacturing?

Yes

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

Do any of your products require a prescription or doctor approval?

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:

Do you have existing insurance coverage in place?

Yes

Carrier Name

Limits of Liability

Expiration Date

Retroactive/ Prior Acts Date

(If applicable) Please upload a hard copy of loss runs from your current carrier:

Excluded Products/Ingredients

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.

Anabolic-Androgenic Steroids
Anabolic Steroids
Androstenedione
Aristolochic Acid
Comfrey (Pyrrolizidine Alkaloids)
DMAA, 1,3-Dimethylamylamine, Dimethylamylamine, Methylhexanamine
Ephedra, Mahuang and Psuedoephedrine
Ephedra/ephedrine Alkaloids
Fenfluramine
Germander
Jin Bu Huan
Colloidal Silver
GHB, GHV (y-Hydroxybutyric acid)
GVL (gamma-valerolactone)
Fenfluramine
Stephania, or any adulterated botanicals
GHB, GHV (y-Hydroxybutyric acid)
Yohimbe
GVL (gamma-valerolactone)

GB; 1, 4 Butanediol
Dendrobium
Glibenclamide,Glyburide, Liqiang 4
Chaparral
Kava, ava, kava-kava and related derivatives
Lobelia
Pennyroyal Oil
Stephania, or any adulterated botanicals
Yohimbe
AMP Citrate, 1,3-dimethylbutylamine citrate, 1,3-dimethylbutylamine HCL, methylpentanamine
Vinpocetine
Vape products and smokable products including but not limited to hemp flower, shatter, and pre rolls
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

Other than what's listed on this application, do you offer any other products or services?

Yes

Please describe:

Have you had any liability or property claims in the last 5 years?

Yes

Please describe:

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:

By checking this box, I agree to the Terms & Conditions.

Terms & Conditions

For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s)proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this application and in any attachments, are true and complete. Insurance Canopy. or the Company is authorized to make any inquiry in connection with this application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance.

Insurance Fraud Warning

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime in certain jurisdictions, and subjects the person to criminal and civil penalties.

State Specific Fraud Warning Statements

The fraud warnings listed below are applicable in the following states: AL, AK, AZ, AR, CA, CO, DE, DC, FL, HI, ID, IN, KY, LA, ME, MD, MA, MN,NE, NH, NJ, NM, NY, OH, OK, OR, PA, TN, TX, VT, VA, WA, or WV. If you are located in one of these states, please take time to review the appropriate warning prior to submitting your claim.

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

Alaska: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona: For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California:For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Delaware: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

District of Columbia: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Maine: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

Minnesota: A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.

Nebraska: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.

West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

*APPLIES TO GEORGIA, VIRGINIA APPLICANTS ONLY: The Insured represents that the information furnished in this application is complete, true and correct. It is further agreed that if the above described declarations and statements are not true, accurate and complete, and are deemed material to the issuance of this Policy, any claim arising from any matter not truthfully, accurately or completely disclosed, or disclosed at all, shall be excluded from coverage.