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  1. Home
  2. (Veracity) CBD/Hemp - Ingestible Insurance Application

(Veracity) CBD/Hemp - Ingestible Insurance Application

Section 1: Company Details

SECTION 2: SPECIFIED PRODUCTS AND COMPLETED OPERATIONS

Total gross receipts from all products and services listed above:

SECTION 3: PROCESSING AND QUALITY CONTROL

SECTION 4: INSURANCE INFORMATION

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

Provide the following for present Product Liability insurance.

SECTION 5: CLAIM HISTORY

SECTION 6: EXCLUDED PRODUCTS/INGREDIENTS

It is agreed there is no coverage afforded under this certificate for the following product(s): Derivatives, related botanicals, and/or extracts whether as a primary ingredient or in combination with other ingredients.

  • 1. anabolic-androgenic steroids;
  • 2. anabolic steroids;
  • 3. androstenedione;
  • 4. aristolochic acid;
  • 5. chaparral;
  • 6. comfrey (pyrrolizidine alkaloids)
  • 7. DMAA, 1,3- Dimethylamylamine, Dimethylamylamine, Methylhexanamine
  • 8. ephedra, mahuang and psuedoephedrine
  • 9. ephedra/ephedrine alkaloids
  • 10. Fenfluramine;
  • 11. GB; 1, 4 butanediol
  • 12. GHB, GHV (Y-hydroxybutyric acid)
  • 13. GVL (gamma-valerolactone)
  • 14. Glibenclamide, Glyburide, Liqiang 4
  • 15. KAVA,AVA, KAVA-KAVA and related derivatives
  • 16. Lobelia
  • 17. Pennyroyal oil
  • 18. Picmalion
  • 19. stephania or any adulterated botanicals
  • 20. yohimbe
  • 21. AMP Citrate, 1,3-dimethylbutylamine citrate, 1,3-dimethylbutylamine HCL, methylpentanamine
  • 22. Dendrobium
  • 23. BMPEA, B­Methylphenethylamine, Acacia Rigidula
  • 24. Vinpocetine
  • 25. Any product, supplement or additive determined by the United States Food and Drug Administration at any time to be a “Class I Health Hazard”. Class I. Health Hazard means a product presenting a reasonable probability that the use of or exposure to it will cause serious adverse health consequences or death

PLEASE CONFIRM THAT YOU HAVE READ AND UNDERSTAND THE PRODUCTS LISTED ABOVE ARE EXCLUDED. PLEASE PUT REQUIRED INITIALS HERE:

SECTION 7: POLLUTION LEGAL LIABILITY

SECTION 8: ADDITIONAL INFORMATION

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

NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY

No fact, circumstance, or situation indicating the probability of a claim or action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, circumstance, or situation, any claim subsequently emanating there from shall be excluded from coverage under the proposed insurance. For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s)proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this application and in any attachments, are true and complete. Beazley Group plc. or the Company is authorized to make any inquiry in connection with this application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance. This application, information submitted with this application and all previous applications, and material changes thereto of which Beazley Group plc. receives notice, is on file with Beazley Group plc. and is considered physically attached to and part of the policy if issued. Beazley Group plc. and the Company will have relied upon this application and all such attachments in issuing the policy. If the information in this application and any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify Beazley Group plc, who may modify or withdraw any outstanding quotation or agreement to bind coverage. The undersigned declares that the person(s) and organization(s) proposed for this insurance understands that:

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

WARRANTY

I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from any prior insurer to Beazley Group plc. Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, partners, directors, officers, and employees. Must be signed by the owner, principal, partner, executive officer, or equivalent (within 60 days of the proposed effective date).

 

Terms & Conditions

Insurance Fraud Warning

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

State Specific Fraud Warning Statements

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© 2013 veracityinsurance.com | All rights reserved.

All policies have conditions, limitations and exclusions, please read the policy for exact verbiage. Claim scenario circumstances vary in nature and similar claims do not guarantee coverage.

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