Phone: (888) 677-6074 | Fax: (888) 347-6302

Application

Due to the length of this application, we suggest scrolling through once to ensure you have all the information needed to complete the form, prior to starting.

Upon submission, any fields required that may have been missed or filled in with invalid data will be marked with red text below each field. Please go back and fix these fields, and make sure you receive a successful confirmation message after submitting this form. If the form is incomplete, it will not be sent.

Quote By Date:

Section 1A. General Information:

Legal Business Name:

Mailing Address:

Type #1: CorporationPartnershipLLCIndividualOther

Type #2: Non-ProfitNot for ProfitFor ProfitOther

Use: RecreationalMedicinalBothNo Cannabis Sales - Other

Operations: CHECK ALL OPERATIONS: CultivationProcessorManufacturerCannabis RetailLabHydroponics RetailSmoke ShopDelivery OperationsTransportationWholesaleOther

Is the Insured a member of any cannabis trade associations?
If Yes, who? CCSENORML-NBNNCIACCIAOther

List your projected sales/donations by category for the next 12 months:

a. Cultivation sales/donations:
b. Manufacturing sales/donations:
c. Processing sales/donations:
d. Recreational/Medicinal cannabis wholesale and retail sales/donations:
e. Sales/donations of accessories/vape units/equip, etc.:
f. Laboratory and testing sales/donations:
g. Other (incl. filling or pre-filled vape cartridges sales/manufacturing)

Total for next 12 months:

What are the total sales/donations for the past 12 months:
New Venture - no prior gross revenue
If New Venture: Do any of the principals have a minimum of 1 year in the cannabis industry

Locations Schedule: Building (0) is used for all outdoor operations

Location #1
Bldg #
Address

Location #
Bldg #
Address

Location #
Bldg #
Address

Location #
Bldg #
Address

Location #
Bldg #
Address

Location #
Bldg #
Address

Location #
Bldg #
Address

Location #
Bldg #
Adress

ENFORCEMENT OF THE CONTROLLED SUBSTANCE ACT

Section 1B.

Please note: All questions should be answered. N/A is NOT an acceptable answer for the carrier to approve.

Information provided on this form will become part of the policy of insurance if issued.

Applicant Name:
Applicant Address:

1. How does the applicant prevent the distribution of marijuana to minors? Please describe:

2. How does the applicant prevent revenue from the sale of marijuana from going to criminal enterprises, gangs, and cartels? Please describe:
3. How does the applicant prevent possible diversion of marijuana from states where medicinal and/or recreational use of cannabis products is legal under state law to states where medicinal and/or recreational use of cannabis products is not legal under state law? Please describe:

4. How does the applicant prevent the use of state-authorized marijuana activity as a cover or pretext for the trafficking of other illegal drugs or other illegal activity?

5. Does the applicant have a program or safeguards in place to prevent violence and the use of firearms in the cultivation and distribution of marijuana?
Please Describe:

6. How does the applicant prevent drugged driving or other possible adverse public health consequences associated with marijuana use? Please describe:

7. Does the applicant either grow or purchase marijuana grown on public lands?
8. How does the applicant prevent the possession or use of their product on federal property?

Applicant's Signature (Typing your name in the box is the equivalent of your signature:

Date:

Section 2 -History

All questions must be answered. Failure to disclose proper history could invalidate any and all coverage.

1. Has any application for similar insurance made on behalf of the applicant and/or any principal, partner, owner, officer, director, employee, manager or managing member thereof or any predecessor, subsidiary or affiliated organization thereof ever been declined, canceled or non-renewed?
2. Do you currently have commercial insurance coverage?

General Liability:

Insurance/carrier:
Expiration Date:
Policy Number:
Premium:
Coverage Limits: Aggregate
Coverage Limits: Occurrence

Property:
Insurance/carrier:
Expiration Date:
Policy Number:
Premium:
Coverage Limits:

Crop:
Insurance/carrier:
Expiration Date:
Policy Number:
Premium:
Coverage Limits:

Excess:
Insurance/carrier:
Expiration Date:
Policy Number:
Premium:
Coverage Limits: Aggregate
Coverage Limits: Occurrence

Product Liability:
Insurance/carrier:
Expiration Date:
Policy Number:
Premium:
Coverage Limits: Aggregate
Coverage Limits: Occurrence

3. Has the applicant had any prior liability and or property claims or losses in the past 5 years:
(If yes, attach currently-valued (within past 90 days) loss runs including details)

4. Complete the following for any applicant or any principal, partner, owner, officer, director, manager or managing member of the applicant or any person(s) or organization(s) proposed for this insurance or any predecessor, subsidiary or affiliated organization:
a. Have any of the above been convicted of a felony or DUI in the last 10 years?
If yes, give details (date/jail time served/felony/misdemeanor):

b. Is the applicant in compliance with all local & state laws regarding the manufacture, control, dispensing of cannabis?
c. Does the Insured currently hold a cannabis license/permit?
If no, when do they expect to be licensed/permitted:

Section 3 - General Liability and Excess

Complete Sections 3 thru 7 for each building and/or outdoor grow

Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

DBA:
Location #
Bldg#
Physical Address:
What are the operations IN THIS BUILDING ONLY!CultivationProcessorManufacturerCannabis RetailHydroponics Retail/WholesaleSmoke ShopDelivery OperationsDoctorLaboratory TestingCannabis Wholesale/BrokerOffice only - No cannabis salesRetail - No cannabis salesTransportationOther

General Building Questions -
Year Building Built: If the building is older than 20 years, the applicant will need to provide the year the following were last worked on or inspected:
Roof
Plumbing
Electrical
HVAC
Construction Type
Number of Stories
Square Footage
Roof Construction
Roof Covering
Are there Fire Sprinklers?
If yes, what percentage of the Insured's building is sprinklered
Is there a central station fire/burglar alarm that is connected to all doors/windows:

General Liability Questions:
1. Does the premise have a pool, pond, or other water exposure?
2. Does anyone live in the above-scheduled building or on-premises?*
3. Are there any dogs on the premises?*
4. Are there any firearms located in the scheduled building listed above?*
5. Does the Insured sub-contract their security guard services?* (If yes: the sub-contracted security company must list you as an additional insured)
6. Does the applicant maintain daily written records of all Cannabis, Hemp, and CBD containing products, including the purchase date, type of product and purchase price?
*If any answer above is yes, please provide details on a separate Word doc.

General Liability Coverage:

$1,000,000 each occurrence/$1,000,000 aggregate$1,000,000 each occurrence/$2,000,000 aggregate$2,000,000 each occurrence/$2,000,000 aggregatePesticide and Herbicide Applicators Endorsement (WA & MA Only)
If you selected Pesticide and Herbicide Applicators Endorsement, please select coverage

Hired and Non-Owned Auto Endorsement:
Include Hired and Non-Owned Auto:
NOTE: Delivery operations are not eligible for HNOA endorsement. Transport for the purposes of business to business is approved. Any delivery to the consumer will be excluded.
1. Do all drivers maintain a personal auto policy and keep it in force at all times?
2. Is any driver allowed to drive with any DUI, DWI, or reckless driving violations?
3. Are MVRs collected by all drivers employed by the applicant?
4. Does applicant or employees of applicant make any deliveries directly to patients or customers from the retail location?

Excess Liability Coverage
Excess Liability Coverage:
Check box if you want to decline excess coverage at this time$1,000,000$2,000,000$3,000,000$4,000,000
(each excess layer added will apply to both the occurrence and aggregate limits)
NOTE: Excess can not be applied if $2,000,000 occurrence was requested under the General Liability

Section 4A. - Property

Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the Insured have an active central station burglar and fire alarm system?
Monitoring Company
2. Are all windows and doors connected to an Active Central Station Alarm?
3. Does the applicant have an approved safe?
Minimum safe and vault requirements: 800lb with a 1-hour fire rating; under 2000lb must be bolted to the ground
4. Does the applicant have an approved vault room?
What is an approved Vault? Click Here
5. Do you have a buzz in system or security personnel at the door?
6. Does the applicant have interior and exterior cameras?
7. Distance to Nearest Building (Provide distance in feet)
North:
South:
East:
West:

Property Coverage and Endorsements for the location listed above:
Optional Property Deductibles (the deductible will default to $2,500 if none are chosen) $10,000$50,000
Building Coverage:
Loss of Income:
Outdoor Signs:
Cannabis Inventory:
Indoor Grow Equipment & Tools:
Outdoor Grow Equipment & Tools:
Business Personal Property:
Tenants Improvements:
Triple net LeaseNamed Insured owns the buildingSole tenant and no other buildings attached
Equipment Breakdown Requested? (excludes plants/cannabis inventory or finished stock
3rd Party Care/Custody/Control ($1mm max limit)
Deductible for CCC:
Manufacturing Equipment:

Property Endorsement If Yes, please complete next section 4B
Form A - $1,000 premium*Form B - $1,500 premium*Form C - $2,000 premium*

Section 4B. - Property Endorsement FORM A, B, or C

Complete this section (4B) for each building where off-premises coverage is wanted

Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Coverages:
See links below for coverage options:
Click Here to view Form A
Click Here to view Form B
Click Here to view Form C

1. Will the Insured transport cannabis living plants to other businesses?
2. Will the Insured transport harvested, processed or finished cannabis to other businesses?
3. Will the Insured deliver any cannabis products directly to the consumer?
4. Will the vehicles that transport the Insured's property and or money and securities from the scheduled premises have an active alarm system?
5. If yes to question 4: does it include Low Jack or some other tracking service?
6. Are drivers allowed to make personal stops when transporting goods?
7. Are drivers allowed to take any cannabis inventory and/or money home?
8. Does the Insured collect DMV records from all drivers prior to employment?
9. Does the Insured allow any firearms or weapons in the vehicles?
10. Does the Insured have a lockbox that is bolted to the vehicles?
11. Does the Insured provide lifts, ride share or other livery type operations?

Are you a grower?

Section 5 - All Cultivation/Processing Operations (Incl. 3rd Party Processing)

Complete section 5 for each building and outdoor operations

Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

Check all that apply:
Location Zoning: CommercialResidentialIndustrialAgriculturalMixed Use

Cultivation Operations: IndoorOutdoorEnclosed GreenhouseOpen Greenhouse

Processing Operations: Drying/CuringQuarantineTrimmingStorage of Finished Stock

Cultivation Questions:
1. Is there a back-up system for the electrical supply:
2. Does the applicant test 100% of the cannabis products grown?
If yes, who provides the testing: Phone #:
3. Estimated number of harvests per year:
4. Average yield of harvested cannabis per plant:
5. Average WHOLESALE value per pound of finished cannabis stock
6. Maximum per plant value based on questions 4 and 5:

Cannabis & Hemp Crop Coverage:

CROP COVERAGE LIMITS
Seeds:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Immature Seedlings:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Vegetative Plants:
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Flowering Plants
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Harvested Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

Crop Value

Finished Stock
Number of Plants
Per Plant Value x
=Total Plant Values (Wholesale)

All Cultivation operations are required to warrant both of the following:

I warrant the above to be true and I understand the insurance contract will be considered based on my warranty:

Section 6 - Cultivation Outdoor/Greenhouse Operations

Complete Section 6 for each Outdoor/Greenhouse building

Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Does the property listed above have fencing surrounding the cultivation area?
A. If yes, please provide details about the fencing used (i.e. Height, Electrified, and Material Used).
B. If yes, is the fenced-in area locked at all times?
2. Is there any barbwire, razor wire, or electrified fencing used for security on property?
A. If yes, are there warning signs on the property?
3. Are there gates at all entrances of the property?
A. If yes, are the gates locked at all times?
4. Are there any traps that are used for security on the property?
A. If yes, please provide details:
5. What percentage of your total cultivation at the location listed above is:
A. Indoor Grown?
B. Greenhouse Grown?
C. Outdoor Grown?
A, B, and C must total 100%

Greenhouse Cultivation Operations:
6. Will the greenhouse be fully enclosed with locking doors?
A. If no, please provide photos and details on how you plan on securing the greenhouse.
7. Will the greenhouse have electricity?
A. If yes, please provide details on equipment that uses electricity:
8. Provide details on the materials used to construct the greenhouse walls (i.e. aluminum frame, glass windows, steel frames, canvas, polycarbonate, etc.)

**PLEASE PROVIDE PHOTOS OF GREENHOUSE(S) AT TIME OF SUBMISSION**

Outdoor Cultivation Operations:
1. What is the total property size
2. What is the size of the total cultivation area where cannabis and/or hemp operations take place

Does your business manufacture or cook cannabis?

Section 7 - Manufacturing/Cooking Operations:

Complete Section 7 for each building that has manufacturing/cooking operations

Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Check box to add an additional building or outdoor grow.

Additional Building or Outdoor Grow

Location #
Bldg#
Physical Address:

1. Will there be open flame cooking and or fryer operations at the property listed above?
A. If yes: Are open flame cooking and/or frying operations conducted under a non-combustible power ventilation hood?
2. What products do you manufacture that require open flame cooking or frying:
3. Does your establishment have an UL-300 compliant automatic fire suppression system with nozzles extended over all cooking surfaces?
A. If yes, what type of fire suppression system is it?
4. Does your cooking/frying equipment have an automatic gas/propane supply cutoff?
5. Does the location list above have deep fat fryer with a high limit temperature switch?
6. How often are your hoods and flues checked?
7. Are hoods and flues inspected/cleaned by an outside service and tagged for verification of this?
8. How often is your fire suppression system serviced?
9. Are fire suppression systems inspected/cleaned by an outside service and tagged for verification of this?
10. How often are the filters in your grease hood cleaned?
11. Have you ever had any health or liquor violations that have resulted in the closing of your business or suspension of your license in the past?
12. Will your operations include extraction of cannabis oils?
A. If yes, what method do you use to extract?
B. If CO2 - how many CO2 detectors are in building?
C. If solvents or gases are used, open or closed loop?
13. Will your equipment be used and or rented to others who are not the named insured?
A. If yes, will you require them to carry their own insurance and name you on their policy?
14. Is the address listed above the only location where your operations are performed?
A. If no, list all addresses and the operations performed at each of the locations. (i.e. short term leases, short term kitchen or lab rentals)

Section 8 -Product Liability Questions

Section 8A - General Questions - All Operations

1. Does the applicant maintain daily written records of all Cannabis, CBD, Hemp, and inventory of non-cannabis products, including purchase date, type of product, purchase price and who it was purchased from?
2. Does the applicant have a quality assurance plan in place?
3. Does the applicant have a product recall plan?
4. Does the applicant test 100% of the Cannabis, CBD, and Hemp products prior to distribution?
A. If yes, does the applicant perform their own testing?
B. If no, provide name of the testing laboratory they are contracted with.
Lab Name:
Contact:
5. Does the Insured use software to track sales and pertinent transaction data such as who, when, and what was purchased?
6. Will the Insured follow, to the best of their abilities, all Consumer Product Safety Commission regulations as it would pertain to the withdrawal and/or recall of defective products?
7. Does the Insured have a communication and complaint handling procedure?
8. Does the Insured know of any products that were either voluntarily or mandatory recalled/withdrawn in the past 5 years?
A. If yes, please provide the total number of recalls/withdrawals the Insured has had in the past 5 years?
9. Does the applicant have current or prior product liability insurance?
A. If yes, please complete the following section about your past and/or current product liability carrier?
Insurer/Carrier Name:
Policy Expiration Date:
Policy Number:
Premium
Coverage Limits:
Aggregate:
Occurrence:
Policy Form Type: Claims MadeOccurrence

Section 8B - Retail Operations

1. What percentage of the applicant's estimated revenue is from the sale of non-cannabis equipment, hardware, or non-ingestible items?
2. Does the applicant obtain and maintain a current copy of a supplier's insurance certificate naming the applicant as Additional Insured from each of the companies the applicant purchases products and/or ingredients from?
3. Does the applicant require each supplier that they contract with to have a minimum of $1,000,000 per occurrence and $2,000,000,000 aggregate limit?
4. Does the applicant require each supplier to have their products tested?
5. Does the applicant maintain supplier's contracts, records, and invoices for 5 years or more?
A. If no, how long does the applicant maintain records?
6. Please complete the "Products List" attached or attach a document listing types of products.

CANNABIS PRODUCT LIST BY TYPE
Cannabis FlowerPre-RollsConcentratesEdiblesTopicalOther



NON-CANNABIS PRODUCT BY TYPE
ACCESSORIES OR MERCHANDISE
Ash TraysBlunt WrapsBong WashConesDab RingsDab TowelGlasswareGrindersBatteriesJoint PapersVape EquipmentJoint RollersJoint Rolling TraysLighter HoldersRoach ClipsScreensTorch LightersVape Battery ChargersOther




Vape cartridges/pens (equipment and accessories) is manufactured or distributed by which kind of vendor:

Section 8C - Cannabis, Hemp, and CBD Cultivation Operations

1. What form of pest prevention is the applicant using? Please explain:

2. Does the applicant apply their own pesticides?
A. If no, does the applicant get a copy of the contracted company's insurance before any work begins?
3. Does the applicant follow all state and federal laws with regards to the use, storage, and disposal of pesticides?
4. Is the applicant aware of any past or current pesticide issues that would result in a loss or claim?

Section 8D - Manufacturing of Infused and/or Processed, Extracted Cannabis, Hemp, or CBD Products

1. Does the applicant use any butane, propane, CO2, or other gases in the manufacturing process?
A. If yes, please provide what gases/solvents the applicant uses:CO2ButanePropaneAlcoholEthanolOther


2. Does the applicant follow all laws, regulations, and ordinances pertaining to the storage, use, and disposal of any gases used in the applicant's process?
3. Does the applicant test 100% of all products manufactured for any level of gas/solvent residue?
A. If yes, will the applicant destroy 100% of the products found with unsafe gas residue(s)?
4. Provide a complete list of products that the applicant manufactures on a Word or Excel document if necessary.
5. List all products that the Insured may not manufacture, but places applicant's label on:

Section 8E - Manufacturing of Equipment and Hardware

1. Provide a complete list of equipment and hardware that the applicant manufactures below or attach a Word or Excel document if necessary.
2. List all equipment and hardware that the Insured may not manufacture, but places applicant's label on below or attach a Word or Excel document if necessary.

Section 8F - Product Liability and Endorsements

Choose your Product Liability Coverage Limits:
$100,000 Claim / $100,000 Aggregate$1,000,000 Claim / $1,000,000 Aggregate$1,000,000 Claim / $2,000,000 Aggregate$3,000,000 CSL$5,000,000 CSLDefense Outside Limits* ($1,000,000 sub-limit)

Choose Retro Date (not automatically included)
1 year Retro Active Date2 year Retro Active Date3 year Retro Active Date4 year Retro Active Date5 year Retro Active Date
***If adding retroactive date, please include the loss runs and premiums for each prior year***

Choose your Product Withdrawal Coverage Limits and Deductibles

$1,000 Deductible$5,000 Deductible
$5,000 Deductible$10,000 Deductible$25,000 Deductible
What is product withdrawal? Click Here to review the coverage information.

I understand that this Products Liability coverage part applied for will apply only to CLAIMS FIRST MADE AND REPORTED to the Company in writing within the period of coverage shown on the certificate of insurance issued with the policy or certificate on the date the policy is canceled or terminated, whichever comes first or as otherwise provided by the policy.
 

Section 9 - Additional Insured

1: General LiabilityPropertyProducts Liability
Additional Insured (check one) LandlordLoss PayeeGovernmental AgencyVendor $100 ea/$250 blanketOther


Location #
Bldg#
Name:
Mailing Address:
City:
State and Zip Code:

2.General LiabilityPropertyProducts Liability
Additional Insured (check one) LandlordLoss PayeeGovernmental AgencyVendor $100 ea/$250 blanketOther


Location #
Bldg#
Name:
Mailing Address:
City:
State and Zip Code:

3.General LiabilityPropertyProducts Liability
Additional Insured (check one) LandlordLoss PayeeGovernmental AgencyVendor $100 ea/$250 blanketOther


Location #
Bldg#
Name:
Mailing Address:
City:
State and Zip Code:

4.General LiabilityPropertyProducts Liability
Additional Insured (check one) LandlordLoss PayeeGovernmental AgencyVendor $100 ea/$250 blanketOther


Location #
Bldg#
Name:
Mailing Address:
City:
State and Zip Code:

Fire and Theft losses of property may be excluded if:
a. The Central Station Alarm System is not active during non-business hours. (All doors and windows must be connected to the central station alarm system).
b. The Video Surveillance System is not recording and backing up for 14 days prior to the loss.
c. The seeds, finished cannabis stock/inventory, money and securities are outside the safe during non-business hours.
d. The minimum safe and or vault requirements have not been met at the time of the loss.
e. The building is over 20 years old and no updates have been done in the last 20 years.
f. The safe or vault does not have a 1 hour fire rating, fire will be excluded unless 100% covered by fire sprinklers.
g. All Vaults must be approved in writing by the underwriter.

Other Conditions: Questions and information provided in this application will become part of the policy of insurance if issued. Other Terms, Conditions and Coverages will be included as part of any insurance policy issued by the insurance company. Those Terms, Conditions and Coverages may differ from what is requested in this application.

I an authorized representative of understand and agree this application and any supplements attached hereto will be relied upon for issuance of any policy. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the company, result in the voiding of the insurance issued in reliance on this application and/or denial of claims under any policy issued.

I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to engage in the activities of my business and I agree to release to the Carrier any documents, records or other information bearing upon the foregoing. I understand and agree these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law.

I understand this insurance is being provided through a surplus lines company and the insurer may not be subject to all the insurance laws and rules in my state and the risk is not protected by the State Insurance Insolvency Fund.

THIS APPLICATION MUST BE SIGNED BY APPLICANT AT BINDING, DATE MUST BE WITHIN 10 DAYS OF INCEPTION DATE. SIGNING THIS FORM DOES NOT BIND THE COMPANY TO COMPLETE THE INSURANCE. COVERAGE BECOMES EFFECTIVE WHEN ACCEPTED BY THE INSURANCE COMPANY



Main Contact:
Phone Number:
Requested Effective Date:
Name of Licensed Insurance Broker:
Name of Appointed Insurance Broker:
Signature of Licensed Insurance Broker:

STATEMENT OF NO LOSS
Agency:
Contact Name:
Phone:
E-mail Address:
Code:
Subcode:
Agency Customer ID:

Named Insured:
Carrier:
NAIC Code:
Policy Number:
Approved By:

I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTS OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER THE INSURANCE POLICY WHOSE NUMBER IS SHOWN ABOVE, FROM 12:01 AM ON TO

RECEIPT
$
AMOUNT RECEIVED BY: