Marijuana Public and Products Liability Proposal Form

All questions must be answered. If not, a quotation may not be provided | You must disclose all material facts. A material fact is one likely to influence an underwriter’s judgment.

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Application Information

Applicant Name*

First Last

Full Names of all Companies*

Email*

Phone*

Registered Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website*

Date Business Established*

MM slash DD slash YYYY

Date from which insurance is required*

MM slash DD slash YYYY

Exact Nature of Business*

Dispensary

Laboratory

Retail

Product Manufacturer

Grow-op Distribution (Indoor)

Grow-op Distribution (Outdoor)

Lounge

1. Public Liability

Please provide details of premises owned/occupied by you*

Is the premises a strip mall or multi-tenanted?*

Strip Mall

Multi-tenanted

What is the third party surrounding property including distances and watercourses?*

Is any work undertaken away from your premises (other than collection/delivery of goods)?*

Yes

N/A

Please provide details

2. Estimated Annual Turnover

(i) Own Manufacture*

(ii) Wholesale*

(iii) Other (please describe)

3. Exports:

Please state estimated annual turnover to

Canada*

Own Manufature

Wholesale

Other

EU Countries*

Own Manufature

Wholesale

Other

USA (No Cover)*

Own Manufature

Wholesale

Other

Own Manufature

Wholesale

Other

Rest of the World

Own Manufature

Wholesale

Other

4. Products:

Please state estimated annual turnover to

Description of Products*

Medical Marijuana

Recreational Marijuana

Recreational Marijuana – Food

Recreational Marijuana – Drinks

Soft Gel Capsules

Others please describe:

If you supply products which you do not manufacture, please confirm whether rights of subrogation are fully maintained against the manufacturer(s) &/or supplier(s)?*

Yes

Do the manufacturer(s) &/or supplier(s) have products liability insurance in force to at least the limits requested hereon?*

Yes

Do Products comply with all relevant:-

(a) Industry and Trade Standards or Government Safety Licensing Regulations or equivalent local legislation?*

Yes

(b) Official Standard or Government Regulations laid down in countries to which Products are exported?*

Yes

Are any new products likely to be marketed during the next 12 months? If YES, please provide details.*

Yes

5. Commercial General Liability - Required Limits

Public Liability Limit $*

Per Occurrence - Coverage is Occurrence

Products Liability Limit $*

Per Occurrence - Coverage is Claims Made

Please provide Retroactive Date and Limit for current cover:*

Requested Deductible: $

6. Liability Underwriting Information:

EXPERIENCE IN THE CANNABIS FIELD:*

7. Certifications, Associations - ETC.

Is the applicant in compliance with all local laws regarding the growth, manufacturing, dispensing and or control of cannabis or cannabis containing products?*

8. Growing Facility Information:

a) Does the applicant grow any cannabis that is intended to be distributed for recreational purposes?*

Yes

If so, what % of revenue? ________%

b) Does the applicant maintain separate records for medical and recreational purposes?*

Yes

c) Are there any cultivation activities outside the building?*

Yes

If so, describe the premises:

What is the maximum number of plants on the premises at any one time?*

e) Are any cannabis products manufactured, mixed, labelled, and relabeled by the applicant including any and all related products?*

Yes

Date of last Health Canada inspection?*

g) Does the applicant use a third party testing laboratory to test their cannabis?*

Yes

If Yes, do all the testing reports received from this lab indicate the following?

Products are not contaminated with pesticides?*

Yes

Products are not contaminated by bacteria?*

Yes

Products are not contaminated by heavy metals?*

Yes

Products are not contaminated by mold/fungus?*

Yes

Products are not contaminated by residual solvents?*

Yes

Cannabinoid profiles? (THCA, delta8-THC, delta9-THC, CBDA, CBD)*

Yes

Terpene Profiles*

Yes

If No, how does the applicant ensure product purity?*

Manufacturing & Processing Operations:

9. Please supply a complete list of products manufactured or processed.*

10. Are there manufacturing and processing outside?*

Yes

If Yes, approx. acres?

11. Will any of the production require open flame, frying or other cooking methods?*

Yes

If Yes, please describe:*

12. Will your operations include the extraction of cannabis oils or concentrates?*

Yes

If Yes, what method is used?

Is the method certified?*

Yes

13. What is the Highest concentration (5%) and Dosage (MG) of active cannabinoids per serving contained in the applicant's strongest (IE. Highest)*

14. Please provide the product name, Concentration (%) and Dosage (MG) of active Cannabinoids per serving*

15. Does the applicant actually produce the individual filled cartidges for Vapour Pens?*

Yes

If Yes, please provide a copy of the applicant’s labeling and packaging for the cartridges evidencing warnings and disclaimers.*

Max. file size: 20 MB.

16. Are all Cannabis containing products manufactured and distrubuted by the applicant sold in child proof packaging or containers?*

Yes

17. Has the applicant consulted with an attorney to determine that their labeling includes: warnings, disclaimers, notification of contradictions and listing of ingredients?*

Yes

18. Does the applicant have a written products recall plan?*

Yes

19. Sales Breakdown:

Products/Operations/Services

UK

Other (Specify)

Medical

Note – coverage not available for U.S. sales

Annual gross receipts from medical cannabis (Leaves, buds, flower and trim)

UK*

Other (Specify)*

Annual gross receipts from infused medical products (baked goods, candies, food or drink)

UK*

Other (Specify)*

Annual gross receipts from medical cannabis oil cartridges or concentrates intended to be used with vapourizers

UK*

Other (Specify)*

Recreational

Annual gross receipts from cannabis (Leaves, buds, flower and trim)

UK*

Other (Specify)*

Annual gross receipts from infused products (baked goods, candies, food or drink)

UK*

Other (Specify)*

Annual gross receipts from cannabis oil cartridges or concentrates intended to be used with vapourizers

UK*

Other (Specify)*

Other

UK*

Other (Specify)*

Gross receipts from: hemp products

UK*

Other (Specify)*

Total:

UK*

Other (Specify)*

20. Exports

(a) A full description of all products exported and approximate percentage of total turnover applicable to each product.*

(b) For how long have you been producing each product?*

(d) Do you comply with the State Federal Laws applicable to each product?*

(e) What is the means of export – is it by?

(i) direct subsidiary in country If YES, please give details*

Does the subsidiary(ies) have their own product insurance(s) in place?*

Yes

(ii) incorporated in part of machinery or commodity sold direct by other manufacturers*

Yes

(iii) sold in country of origin to selling Agent*

Yes

(f) Does the seller or supplier carry products liability insurance? Please state the Limit of Indemnity applicable if known.*

21. Overseas Exposures

(a) Do you have any representation outside your main territory?*

Yes

(If YES, please give details)

22. Imports

If you import products please state from which countries these are obtained and approximate percentage of total turnover against each.*

23. Design / Specification

(a) Please give full details and percentage of total turnover of products that are:

(i) manufactured/supplied to own design/specification/formulation*

(ii) manufactured/supplied to a design/specification/formulation laid down by a customer*

(b) Do you have a separate design team?*

Yes

If YES, what are their technical qualifications and practical experience?

24. Quality Control

Do you have a written statement relating to Quality Control?*

Yes

If YES, please provide a copy or indicate its main features.

Does Quality Control involve:

(i) specified minimum standards or procedures?*

Yes

(If YES, please state them)

(ii) the testing of a sample percentage of the goods?*

Yes

(If YES, please provide details)

(iii) Are sampling inspections made on incoming raw materials and incoming parts?*

Yes

(iv) What is the procedure for dealing with customer complaints?*

(v) Are records of complaints retained?*

Yes

If YES, for how long?

(vi) Is it possible to trace the ultimate customer of individual products or batches in order to recall the products?*

Yes

(vii) Is there an emergency product recall procedure?*

Yes

(viii) Details of any products withdrawn or recalled from the market during the past 10 years*

25. Records

Does Quality Control involve:

(i) source of Product/raw materials/component parts purchased?*

Yes

(ii) source of design of Products manufactured?*

Yes

(iii) Quality Control and testing procedures effective at the time of design and/or manufacture?*

Yes

(iv) Research undertaken to minimise risk to health and safety?*

Yes

(v) How long are the records for the above [(i), (ii), (iii) & (iv)] kept for?

26. Claims

Have any claims or incidents occurred during the last 5 years resulting, or alleged to have resulted, in death, injury or disease to third parties or damage to their property? Are you aware of any circumstances which might give rise to a claim?*

Yes

If YES, please give details.

Date of Loss

Brief details of incident and whether or not an insurance claim has been made

Paid amount

Insurers Outstanding Reserve

Total Incurred

27. Limit of Indemnity for public and products Liability

Please state Limit(s) of Indemnity for which a quotation is required:*

28. Insurer Details

Has any Insurer ever declined your proposal, refused to renew or cancelled your policy?*

Yes

If YES, please give details.

29. Declaration

I/We declare that to the best of my/our knowledge and belief the above statements are true and complete and will form part of the contract between me/us and the Underwriters. I/We undertake to inform Underwriters of any material alteration of the facts occurring prior to the completion of the contract of insurance.*

Name and position of person completing the proposal

Name*

First Last

Position*

Signed*

Date*

MM slash DD slash YYYY

File Attachments

Drop files here or

Max. file size: 20 MB.

Wrapping Up

How were you referred to us?

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge*

Yes

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Form Test

Marijuana Public and Products Liability Proposal Form

Application Information

1. Public Liability

2. Estimated Annual Turnover

3. Exports:

4. Products:

Do Products comply with all relevant:-

5. Commercial General Liability - Required Limits

6. Liability Underwriting Information:

7. Certifications, Associations - ETC.

8. Growing Facility Information:

Manufacturing & Processing Operations:

19. Sales Breakdown:

Products/Operations/Services

UK

Other (Specify)

Medical

Note – coverage not available for U.S. sales

Recreational

Other

Gross receipts from: hemp products

Total:

20. Exports

21. Overseas Exposures

22. Imports

23. Design / Specification

24. Quality Control

25. Records

26. Claims

27. Limit of Indemnity for public and products Liability

28. Insurer Details

29. Declaration

Wrapping Up

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