Columbia, SC 29250-5866,
Phone: (800) 622-7370
Fax: (803) 256-4017
Email:
Section-1-GeneralInformation:
Companyname:
DBA:
Mailingaddress:
Main contact:Phonenumber_EmailAddress_
Corporation
Partnership
LLC
Individual
Non-profit
Notforprofit
ForProfit
Past12 monthsNext12months
AnnualGrossWholesaleIncome:$$
AnnualGrossRetailIncome$$
ADDITIONALINSURED(i.e.landlord,losspayee)–Iftherearemorethen1,pleaseattachseparatepaper.
Location
Name:_
Address:_
Section2-ClaimsHistory:
Allquestionsmustbeanswered.Failuretodiscloseclaimshistorycouldinvalidateanyandallcoverage.
1.HasanyapplicationforsimilarinsurancemadeonbehalfoftheApplicantand/oranyprincipal,partner,owner,officer,director,employee,managerormanagingmemberthereoforanypredecessor,subsidiaryoraffiliatedOrganizationthereofeverbeendeclined,cancelledor
non-renewed?YesNo
2.Doyou currently have insurancecoverage?YesNo InsurerPolicy number Coveragelimits Premium ExpirationDate
3.HastheapplicanthadanypriorLiability andorPropertyclaimsinthepast5years: YesNo
Ifyespleaseprovidedetailsabouttheclaim:
4.Hasoristheapplicantoranyprincipal,partner,owner,officer,director,employee,managerormanagingmemberoftheApplicantoranyperson(s)ororganization(s)proposedforthisinsuranceoranypredecessor,subsidiaryoraffiliatedorganization:
A.Hasbeenconvictedforanactcommittedinviolationofany lawincluding trafficin the last 10years Yes _ No __
B.Istheapplicantincompliancewithalllocal statelaws that governthemanufacture,control,dispensing
ofcannabis?YesNo
Section3-LocationandPropertycoverage–completethispageforeachlocation
Location
Physicaladdress:
Whataretheoperationsatthislocation:
Yearbuildingbuilt:
ifthebuildingisolderthan20yearstheapplicantwillneedtoprovidetheyear
thefollowing werelastworkedon.Roof
Plumbing
Electrical
ConstructiontypeNumberofstories:
Squarefootage
ArethereFireSprinklers Yes
Questions:
No
Whatpercentageofthebuilding isSprinkled%
1.DoestheapplicanthaveanActiveCentral StationAlarm SystemYes
No
2.Areall windowsand doorsconnectedtotheCentralStationAlarm:Yes
No
3.Doestheapplicanthaveanapprovedsafe: No
WeightFireRating
Yes
Minimumsafeandvaultrequirements:800lbwitha1hourfireratingandboltedtotheground
4.Doestheapplicanthave VideoSurveillancethatrecordsandbacksup for14days:Yes
No
5.Doesthe entrancetothelocationlistedonthispagehaveadoubleentrance:Yes
No
6.Arethereanyfirearmson the property:Yes
No
7.Doesthe insuredsub-contracttheirsecurity guardsYes
No
a.Ifyes:dotheynamethe applicant asanadditional insured:YesNo
8.Doestheapplicantmaintainwrittenrecordsofallcannabisandcannabiscontaining
products,includingthepurchasedate,typeofproductandpurchaseprice?Yes
No
Liabilitycoveragerequested:
$1,000,000eachoccurrence/$1,000,000aggregate
$1,000,000eachoccurrence/$2,000,000aggregate
GovernmentalActions:Yes
No
$5,000eachoccurrence/$10,000aggregate
PropertyCoverage’satthislocation:
Building Coverage:$
LossofIncome$
LossofRents$
Outdoor Signs$ CannabisInventory/Products$GrowEquipment$ BusinessPersonalProperty $ TenantsImprovements $
Numberofmonths Numberofmonths
Included property forms
•Limitedwater damage
$25,000
•Propertyofothers
$10,000
•Glass Coverage
Property EnhancementYes
Cargo/ TransportYes
No No
$15,000BLANKETCOVERAGE
$2,500PERANYONELOSS$10,000PERPOLICY
Section4-CultivationQuestionsCoverage–completethispageforcultivationlocation
checkbox ifthereareNO cultivationoperationsandskip page3
Location
PhysicalAddress:
GrowOperations(Checkallthatapply)
CommercialResidentialIndustrialOther_
Indoor
Questions
Outdoor _Greenhouse Other
1.Isthereaback-upsystem forthe electricity supply?Yes
No
2.Whatarethehoursofoperations?
3.Doestheapplicant test100%ofthecannabisproducts grown?Yes
No
Ifyes:Whoprovidestesting:
4.Estimatednumberofharvestsperyear
5.Averageyieldofharvestedcannabisperplant
(oz)
6.Averagewholesalevalueperpoundoffinishedcannabisstock
7.MaximumperplantvaluebasedonQuestions5.and6.
CropCoverageLimits: NumberofPlantsPer Plant ValueTotalPropertyCoverage
Seeds#
x$=$
ImmatureSeedlings#
x$=$
VegetativePlants#_ x$=$
FloweringPlants#_ x $=$
HarvestedPlants#_ x$=$
Finished Stocklbx $=$
Totalcrop value to beinsured$
AllCultivationoperationsarerequiredto warrantoneofthefollowing:
Ihaveusedorwillusealicensed,insuredcontractorforallelectricalworkatmygrowfacility.
Ihavehadorwillhavewithin30days,allthewiringinspectedbyalicensed,insuredcontractoratmygrowfacility. IwarranttheabovetobetrueandIunderstandtheinsurancecontractwillbeconsideredbasedonmywarranty:
ApplicantSignature
//Date:
AdditionalRequirements:
1.FireandTheft lossesofpropertymaybeexcludedif
a.CentralStationAlarmSystemisnotactiveduringnon-businesshours.(Alldoorsandwindowsmustbeconnectedtothecentralstationalarmssystem).
b.TheVideoSurveillanceSystemsisnotrecordingandbackingupfor14dayspriorto theloss.
c.Seeds,finishedcannabisstock/inventory,moneyandsecuritiesareoutsidethesafeduringnon-businesshours.
d.Morethan25%oftheinsurablevalueofSeeds,finishedcannabisfinishedstockinventory,moneyandsecuritiesareoutsidethesafeduringbusinesshours.
e.Ifthesaferequirementshavenotbeenmetatthetimeoftheloss.
f.Ifthebuildingisover20yearsoldandnoupdateshavebeendoneinthelast20years.
OtherConditions:Underwritersmayinsertoneorallofthefollowingclausesinthepolicy,ifissued:
•DeductibleClause•LocationLimitation•InvalidPaymentsClause(excludedlossesduetobadchecks,creditcardsfraud,etc.);•ProtectionsClause(alarmssafesmustbemaintainedasperdeclarationinproposal);•LockedShowcaseWarranty(ifapplicableforallretailriskswithshowcases);•OpeningClosingWarranty(ifapplicableforretaillocations);•SurveyRequirementsClause-surveyrequirementstobecompliedwithin30days;•ServiceofSuitClause(USA)(legaldisputesmaybebroughtagainstUnderwritersintheU.S.);
•LossSettlementClause:LossestobesettledatWholesaleCostPriceunlessotherwiseagreed.
Name ofauthorizedapplicant
I
Company name
anauthorizedrepresentativeof
understandandagreethisapplicationandanysupplementsattachedheretowillberelieduponforissuanceofanypolicy.Ifurtherunderstandandagreethatfailuretoprovideatrueandaccurateresponsetotheforegoingquestionsmay,attheoptionofthecompany,resultinthevoidingoftheinsuranceissuedinrelianceonthisapplicationand/ordenialofclaimsunderanypolicyissued.
Iauthorizeandconsenttoinvestigationsofinformationbearinguponmoralcharacter,professionalreputationandfitnesstoengageintheactivitiesofmybusinessincludingauthorizationtoeverypersonorentity,publicor private,toreleaseallLloyd’sofLondonparticipatingsyndicates,anydocuments,recordsorotherinformationbearingupontheforegoing.Iunderstandandagreetheseinvestigationsshallnotbeconfinedtoinformationsubmittedinthisapplication,butshallincludeanyothersourcesofinformationdeemedrelevantbytheCompanyasmaybeauthorizedbylaw.
Iunderstandthisinsuranceisbeingprovidedthroughasurpluslinescompanyandtheinsurermaynotbesubject toalltheinsurancelawsandrulesinmystateandtheriskisnotprotectedbytheStateInsuranceInsolvencyFund.
THISAPPLICATIONMUSTBESIGNEDBYAPPLICANTWITHIN30DAYSOFBINDING.
SIGNINGTHISFORMDOESNOTBINDTHECOMPANYTOCOMPLETETHEINSURANCE.COVERAGEBECOMES
EFFECTIVEWHENACCEPTEDBYTHEINSURANCECOMPANY
//
ApplicantsSignatureDatesignedTitle
// RequestedEffectiveDate
Nameofappointed insurance brokerageSignatureofbroker