Vitamins, Supplements & Nutraceuticals Insurance Application

Section 1: Company Details

Company:

Contact Name:

Mailing Address:

City:

State:

Zip:

Is your Physical Address the same as your Mailling Address?

Yes

Business Street Address:

City:

State:

Zip:

Mobile Phone:

Fax:

Email:

Website:

The date your company was established:

Number of Full-time Employees:

Number of Part-time Employees:

How did you hear about us?

Please specify

Other business type

Are you controlled by, owned by, or commonly owned, affiliated or associated with any other organization?

Yes

If yes, please provide details:

Do you have a policy with Insurance Canopy currently?

Yes

SECTION 2: SPECIFIED PRODUCTS AND COMPLETED OPERATIONS

Provide the following information for those products and/or services for which you want coverage. 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 ($):

Prior Year ($):

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:

Have you discontinued or are you considering discontinuing any product or service listed above?

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, please explain:

Do you have a quality control and testing procedure?

Yes

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

Do you comply with Good Manufacturing Practices (GMP)?

Yes

If you are a distributor, do you require your contract manufacturer to comply with GMP?

Yes

Do all records show the date and to whom each product was sold?

Yes

Do you require certificates of insurance evidencing Products Liability Insurance from suppliers?

Yes

Who designs your products?

Are product designs reviewed, tested, and verified by others?

Yes

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 use in children?

Yes

Do you provide any products for use in pre-natal or post-natal care?

Yes

Do any of your dietary supplements carry United States Pharmacopeia (USP) or National Formulary (NF) seal on the label?

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:

SECTION 4: INSURANCE INFORMATION

Limits of Liability Requested:

Deductible:

The company does not guarantee to offer any of the above limits and/or deductibles.

Is the product currently insured?

Yes

Insurance Company

Limits of Liability

Deductible/SIR

Premium

Expiration Date

Retroactive/ Prior Acts Date

Has any insurer declined, canceled, or nonrenewed any Product Liability insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?

Yes

If yes, please provide details:

SECTION 5: CLAIM HISTORY

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 6: EXCLUDED PRODUCTS/INGREDIENTS

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

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:

SECTION 7: POLLUTION LEGAL LIABILITY

Are business operations operated out of a personal residence?

Yes

Are you currently aware of any environmental conditions which could reasonably be expected to give rise to a claim?

Yes

If yes, please explain:

Are there any above ground or underground storage tanks of capacity greater than 250 gallons located on the premises?

Yes

If yes, please attach tank schedule

If yes, do these tanks meet EPA 1998 upgrade requirements?

Yes

Are any goods, products, or materials that are stored or used for any purpose at the insured location classified as being of a flammable, combustible, or explosive nature?

Yes

If yes, please provide a listing of all goods, products, or materials with a description as to how they are stored and any fire and/or spill prevention and control measures (i.e., sprinkler system) in place below:

Have you during the last 5 years been cited and/or prosecuted for contravention or violation of any standard or law relating to any release from your premises of any substance into sewers, rivers, seas, air, or onto land?

Yes

If yes, please describe:

SECTION 8: ADDITIONAL INFORMATION

As part of this Application attach the following: Brochures, Labels, and Instructions.

NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY

If you do not have product labels and ingredients on your provided website URL, you may provide them in a file here.

No fact, circumstance, or situation indicating the probability of a claim or action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, circumstance, or situation, any claim subsequently emanating there from shall be excluded from coverage under the proposed insurance. 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. Beazley Group plc. 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. This application, information submitted with this application and all previous applications, and material changes thereto of which Beazley Group plc. receives notice, is on file with Beazley Group plc. and is considered physically attached to and part of the policy if issued. Beazley Group plc. and the Company will have relied upon this application and all such attachments in issuing the policy. If the information in this application and any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify Beazley Group plc, who may modify or withdraw any outstanding quotation or agreement to bind coverage. The undersigned declares that the person(s) and organization(s) proposed for this insurance understands that:

The policy for which this application is made applies only to “Claims” first made during the “Policy Period”
Unless amended by endorsement, the limits of liability contained in the policy shall be reduced and may be completely exhausted by “Claim Expenses” and, in such event, the Company will not be liable for “Claim Expenses” or the amount of any judgment or settlement to the extent that such costs exceed the limits of liability in the policy
Unless amended by endorsement, “Claim Expenses” shall be applied against the “Deductible.”