NutriPRO Insurance Application for VitaQuest

NutriPRO Insurance Application
Page 2: Coverages and Insurance History
2.1 Coverage Type Requested*

General Liability INCLUDING Products & Completed OperationsProducts & Completed Operations ONLY
Proposed Effective Date*

MonthDayYear
Proposed Expiration Date

MonthDayYear
Policy period
The provided Effective and Expiration dates would make this a short-term policy. Please provide reason for requesting a short-term policy. If you meant to request a standard policy period of 1 year, please correct the dates above.
The provided Effective and Expiration dates are longer than a standard policy. Please provide a reason for this request. If you meant to request a standard policy period of 1 year, please correct the dates above.

2.3 Limits Requested

	Per Occurrence Limit	Aggregate Limit	Deductible Requested
Limits

2.3 Per Occurrence/Aggregate Limits Requested
Deductible Requested
2.4 Please list any additional limit or coverage requests
2.5 Which best describes the Applicant's current insurance status?*
2.5b Please Provide Retroactive Date(s) Below
2.5b When did Applicant begin selling products? *

MonthDayYear
If Applicant hasn't started selling, enter the approximate date they expect to begin selling.
2.5b Please explain why Applicant does not currently have insurance coverage.
2.6 Has the Applicant had any claims, demands, or circumstances in the past 5 years which are relevant to the insurance for which they are seeking coverage on this application?*

YesNo
2.6b Please provide details
2.7 Are any persons or organizations proposed for this insurance aware of any fact, incident, circumstance, situation, condition, defect or suspected defect which may result in a claim that would fall under this proposed insurance?*

YesNo
2.7b Please provide details
2.8 Has any insurance company ever cancelled, restricted or refused to renew the applicant's insurance, for which they are applying for coverage on this application?*

YesNo
2.8b Please provide details
2.9 Please provide details of Applicant's prior insurance coverage.
Five years of currently valued loss runs must be submitted for review PRIOR to binding any quote. Please upload here if available.

Cancelof

NutriPRO Insurance Application
Applicant's selling operations
3.7 Please provide a breakdown of where products are sold
Domestic Sales(US/Canada)*
Domestic and Foreign Sales must equal 100%
Foreign Sales*
Domestic and Foreign Sales must equal 100%
Total Sales Percentage
Please answer the following questions about the Applicant's own products
3.8 Who manufactures the Applicant's end-products?
3.8b What percentage of the Applicant's products are manufactured/processed by the Applicant?
3.9 Breakdown of where the Applicant's products are Manufactured

Please provide the percentage breakdown of where Applicant's products are Manufactured
Domestic Manufacturers (US/Canada)
Domestic and Foreign must equal 100%
Foreign Manufacturers
Domestic and Foreign must equal 100%
Total Sales Percentage
3.9b Please provide names and city/state (or city/country) of the manufacturers contracted to manufacture the Applicant's products
3.10 Is the Applicant listed as an "Additional Insured- Vendor" on the product liability insurance of the 3rd party products they sell?

YesNoVaries depending on the product
3.11 Breakdown of where the Applicant sources the raw ingredients they sell

Please provide the percentage breakdown of where Applicant sources the raw ingredients they sell
Domestic Suppliers (US/Canada)
Foreign Suppliers (Rest of World)
Cultivated, grown, or harvested by Applicant
Total
3.11b Please provide names and city/state (or city/country) of Applicant's suppliers

NutriPRO Insurance Application
Applicant's manufacturing operations
3.12 Who is responsible for sourcing the ingredients used to manufacture 3rd party products?*
3.13 Breakdown of where applicant sources the ingredients used to manufacture their products
Domestic Suppliers (US/Canada)*
Domestic and Foreign must equal 100%
Foreign Suppliers*
Domestic and Foreign must equal 100%
Total Supplier Percentage
3.13b Please provide names and city/state (or city/country) of ingredient suppliers of manufactured products*

NutriPRO Insurance Application
Page 5: Questions about Specific Ingredients
Questions about Specific Ingredients

Enter the percentage of total sales generated by the following ingredients

	% of total Sales
Aconite, Aconitine, devil’s head, monkshood
Animal Derived Products
Aristolochic Acid/Aristolochia
Bitter Orange/Citrus Aurantium/Synephrine
1,4 Butanediol (BD)
Caffeine
CBD, Cannabidiol
Chaparrel
Chomper
Colloidal Silver
Comfrey
Delta 8 Tetrahydrocannabinol
DMAA, 1,3-dimethylamylamine, AMP Citrate
DMBA, 1,3-dimethylbutylamine/ 4-Amino-2Methylpentantane Citrate
DHEA – Dehydroepiandrosterone
Ephedra/Pseudoephedrine/MaHuang
Gamma Hydroxybutric Acid, Gamma Hydroxy Butrate (GHB), Gamma Butyrate (GBL)
Gamma Butyrolactone (GBL)

	% of total Sales
Germander
Germanium
Hemp
Hoodia
Hydroxycitrate
Jin Bu Huan
Kava
Kratom, Biak, Cratom, Mitragyna speciosa
Lobelia
L-Tryptophan
Magnolia
Octodrine, 1,5-Dimethylhexylamine (DMHA)
Pennyroyal Oil
Phenibut, 4-Amino-3-Phenylbutyric Acid
Steroid or Hormone Precursors
Triiodothyroacetic Acid (TRIAC),Tiratricol
Yohimbe

5.1 Are any products derived from hemp, including hemp-derived CBD?*

YesNo
5.1b Do any of Applicant's Delta-8 THC, Delta-9 THC, or any other psychoactive substance?*

YesNo
5.1b Explanation: Please provide details.
5.1c Please enter percentage of total sales from hemp derived products*
5.2 Does applicant sell vaping liquids, cartridges, devices, or accessories?*

YesNo
5.2 Explanation: Please describe/list the vaping liquids, cartridges, and/or devices sold by the Applicant.
5.2b Please enter percentage of total sales from vaping liquids, cartridges, and accessories. *

FRAUD WARNING

NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
FRAUD WARNING

NOTICE TO COLORADO APPLICANTS: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
FRAUD WARNING

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
FRAUD WARNING

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
FRAUD WARNING

NOTICE TO HAWAII APPLICANTS: 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.
FRAUD WARNING

NOTICE TO KENTUCKY APPLICANTS: 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.
FRAUD WARNING

NOTICE TO LOUISIANA APPLICANTS: 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.
FRAUD WARNING

NOTICE TO MAINE APPLICANTS: 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.
FRAUD WARNING

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
FRAUD WARNING

NOTICE TO NEW MEXICO APPLICANTS: 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.
FRAUD WARNING

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim for each such violation.
FRAUD WARNING

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
FRAUD WARNING

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

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for insurance or statement of a 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 subjects the person to criminal and civil penalties.
FRAUD WARNING

NOTICE TO TENNESSEE APPLICANTS: 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.
FRAUD WARNING

NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material facts.

The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such changes at our sole discretion. Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and made a part of this application.

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
the underwriting manager, Company and/or affiliates thereof.

Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, principals, 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).
Name of person signing document*

First NameLast Name
Title*
Signature

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Date Signed

MonthDayYear
Date
Insurance Agent's Name

First NameLast Name
Application Version
Should be Empty:

NutriPRO Insurance Application

Page 1: Applicant Information

1.7 Key Contact

NutriPRO Insurance Application

Page 2: Coverages and Insurance History

NutriPRO Insurance Application

Page 3: Revenue & Operations

3.2 Revenue history for previous five years

3.3 Applicant's Operations:

NutriPRO Insurance Application

Applicant's selling operations

3.7 Please provide a breakdown of where products are sold

Please answer the following questions about the Applicant's own products

3.9 Breakdown of where the Applicant's products are Manufactured

3.11 Breakdown of where the Applicant sources the raw ingredients they sell

NutriPRO Insurance Application

Applicant's manufacturing operations

3.13 Breakdown of where applicant sources the ingredients used to manufacture their products

NutriPRO Insurance Application

Page 4: Product Details

NutriPRO Insurance Application

Page 5: Questions about Specific Ingredients

Questions about Specific Ingredients

NutriPRO Insurance Application

Page 6: Legal, Quality Control and Quality Assurance (QA/QC)

NutriPRO Insurance Application

Page 7: Regulatory Questions