Sadler

Instructions: Answer all questions. If the answer is NONE, please state “NONE.” Attach copies of all labels including the ingredients with the application. Application must be signed and dated by an officer of the company

A. Applicant

1. Company Name(s)/Insured:

Include all DBA's. If Sole Proprietpr, FIrst and Last Name of the Owner and DBA's.

2. Business Entity:

Contact Name:

Email Address:

3. Physical Address:

City:

State:

Zip:

4. Mailing Address:

City:

State:

Zip:

5. Phone:

Fax:

Website:

6. Date Business Started:

Requested Effective Date of Insurance:

7. Number of Full Time Employees:

Number of Part-Time Employees:

Federal Tax ID:

8. Estimated Annual Employee Payroll:

Does the applicant have a policy with Veracity currently?

Yes

B. Sales and Marketing Data

1. Please list products you manufacture, distribute, and/or import. Please provide breakdown of sales for each product.

2. Sales Exposure Information

Next 12 months (Projected)

Domestic Sales:

US, Canada & US Territories

Foreign Sales:

Outside of US Territories

Total Sales:

Last 12 Months (Expiring)

Domestic Sales:

US, Canada & US Territories

Foreign Sales:

Outside of US Territories

Total Sales:

1st Prior

Domestic Sales:

US, Canada & US Territories

Foreign Sales:

Outside of US Territories

Total Sales:

3. Other than those listed on this application, do you have any operations or sell any products under the company name(s) /insured listed above?

Yes

Please Describe:

4. Do you plan to manufacture, distribute, or import any new products in the next 12 months?

Yes

Please Describe:

5. Have you discontinued manufacturing, distributing, or importing any products within the past 5 years or have plans to discontinue any product listed above?

Yes

Please Describe:

6. Do you sell any of your products direct to consumers at a retail location you operate?

Yes

How many retail locations do you operate?

7. Do you ever host or participate in special events on or off your premises?

Yes

C. Liability Insurance Information

1. Please Indicate Liability Limits Desired: (i.e. $1,000,000 Each Occurrence, $2,000,000 Aggregate and $2,000,000 Product Liability)

Each Occurrence Limit:

Aggregate Limit:

Product Liability:

2. Excess General Liability Limits:

If applicable.

Other Limit:

3. Do you currently have General Liability Insurance?

Yes

Insurance Carrier:

Number of Years Insured:

Expiration Date:

Retroactive Date / Prior Acts Date

If applicable.

Expiring Premium:

4. Has any insurer declined, cancelled or non-renewed any product liability insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?

Yes

Please Describe:

5. Has the applicant had any liability claims in the past 5 years?

Yes

Please Provide the Following Information:

6. Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, defect or suspected defect which may result in a Liability claim?

Yes

Please Describe:

D. Products

1. Do you import any products from other countries?

Yes

List Countries:

2. Do you export products?

Yes

3. Do you have foreign operations?

Yes

4. Please confirm that you understand that alcoholic products, any product containing (CBD) with more than 0.3 percent THC, any product developed with or containing human stem cells or human stem cell media, drugs, medicines, or products requiring a prescription, Formaldehyde or products containing Formaldehyde, furniture, ingestible hemp or CBD products, invasive body inks or permanent cosmetics, invasive products intended to remain within the body, inversion tables, nail curing lights, Nutraceuticals, Pharmaceuticals, plugin electrical products, suppositories, tanning beds or equipment, toys (except when sold in conjunction with an eligible beauty product), vitamins or supplements are excluded from the policy and there will be no coverage for claims arising out of these products.

I Understand and Agree:

5. At any time have you manufactured, sold, distributed, or imported any of the following products or ingredients: Acetone Products, Aerosol Products, Products Containing Hemp, Digestible Products of Any Kind, Products Containing Talc.

Yes

Describe Product:

6. Do you make or handle any product that is explosive, flammable or poisonous either by itself or in combination with other materials?

Yes

7. Could any of your products be classified as pharmaceuticals?

Yes

8. Are your products generally regarded as safe?

Yes

9. Do any of your products contain color additives regulated by the FDA?

Yes

Is the additive approved?

Yes

10. Do any of your products contain CBD?

Yes

a. How long have you been selling CBD products?

b. Do you source your CBD from legally grown Hemp plant as described in the H.R.2- Agricultural Improvement Act of 2018?

Yes

c. Do you claim in any of your marketing and promotional materials that your CBD products are intended for use in the diagnosis, cure, mitigation, treatment, or prevention of diseases?

Yes

d. What percentage of sales relate to CBD products?

e. Do any of your products have ingestible CBD exposure?

Yes

What percentage of sales?

E. Risk Transfer

1. Do your suppliers provide you Additional Insured status under their general and product liability policy?

Yes

2. Do you provide “Hold Harmless” status to your suppliers

Yes

F. Loss Control and Prevention

1. Have your products ever been investigated for safety by any governmental agency?

Yes

Provide Details:

2. Do you have a written products recall plan?

Yes

Provide a copy of your products recall plan:

3. Have you ever recalled products because of a potential product safety hazard?

Yes

Provide details and indicate percent of recovery:

4. Can you determine, based on available records, for all products you have sold:

a. when any given product was manufactured?

Yes

b. to whom it was sold, and the date of sale?

Yes

c. who supplied parts and supplies going into the final product?

Yes

5. Do you maintain copies of old instruction or operation manuals and advertising material?

Yes

6. Do you do your own formulating and design work for all products?

Yes

7. Do you maintain records of design changes and reasons justifying these changes?

Yes

8. Are your designs subject to independent external review, testing or certification?

Yes

9. Are warranties obtained from all suppliers?

Yes

10. Are quality control records kept so that you can identify at a later date what tests you applied to a given product at a given time?

Yes

11. Do warning labels comply with federal statutory warning labeling requirements?

Yes

12. Does all product labeling comply with FDA guidelines?

Yes

13. Do you expressly disclaim or limit warranties for your products?

Yes

14. Do you provide any specific training/instructions for the user in the proper use of your product?

Yes

15. Do you have a procedure to record data on product related complaints, accidents, or injuries?

Yes

16. Does your procedure provide for examining and preserving any allegedly defective product,with the results of such examination recorded?

Yes

G. Property Coverage

Do you need property coverage?

Yes

Construction type:

Frame/Brick Veneer

Masonry

Metal

Year Built:

Number of Stories:

Square Footage:

Is building over 25 years old?

Yes

Year of Update For Heating:

Year of Update for Electrical:

Year of Update For Roof:

Year of Update For Plumbing:

Distance From Fire Station:

In Miles

Distance From Fire Hydrant:

In Feet

Is the building sprinklered (Fire suppression system)?

Yes

What Percentage:

Do you have an alarm?

Yes

What Type:

Local Gong

Central Station

Fire and/or Burglar

Is the property located within 5 miles of any coast?

Yes

Coverage Information:

Building If Owned

Limit of Insurance:

Deductible:

Policy Form:

Co-Insurance:

Valuation:

Business Personal Property

Limit of Insurance:

Deductible:

Policy Form:

Co-Insurance:

Valuation:

Business Income

Limit of Insurance:

Deductible:

Policy Form:

Co-Insurance:

Valuation:

Lien Holders/Mortgage Holders

Prior Property Carrier/Claims:

Do you currently have Property coverage?

Yes

Current Insurance Carrier:

Number of Years Insured:

Expiring Premium:

Have you had any claims in the past 5 years?

Yes

Claims:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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 subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).

Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

Applicable in 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.

Applicable in Florida and Oklahoma: 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 (In FL, a person is guilty of a felony of the third degree).

Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in Maine, Tennessee, Virginia and 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 a denial of insurance benefits.

Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

Signature of Applicant:

Date:

Title:

Officer, partner, owner, etc.

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