• NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Page 1: Applicant Information

  • 1.3 When did Applicant Began Operations?*
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  • 1.4 Does the Applicant have any parent, sister, affiliate, or subsidiary companies?*
  • 1.5a Does the Applicant's Physical Address match their Mailing Address?*

  • 1.7 Key Contact

  • Format: (000) 000-0000.
  • 1.8 Do you have an insurance agent with whom you want to continue working?
  • Format: (000) 000-0000.
  • 1.9 Is the insured a member of industry associations or organizations?
  • 1.10 Does the insured have any 3rd party cGMP* and/or quality certifications?
  • NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Page 2: Coverages and Insurance History

  • 2.1 Coverage Type Requested*
  • Proposed Effective Date*
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  • Proposed Expiration Date
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  • Rows
  • 2.5b When did Applicant begin selling products? *
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  • 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?*
  • 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?*
  • 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?*
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  • NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Page 3: Revenue & Operations

  • 3.2 Revenue history for previous five years

  • 3.3 Applicant's Operations:

    Check box of all applicable operations.
  • Applicant's Selling operations: Mark all that apply*
  • Applicant's manufacturing operations: Mark all that apply*
  • 3.4 Does Applicant service or install any products for others?*
  • 3.5 Have there been any mergers, acquisitions, or divestitures over the last five years?*
  • 3.6 Does the Applicant anticipate any material changes in products or operations?*
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  • NutriPRO Insurance Application

    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

    Please provide the percentage breakdown of where Applicant's products are Manufactured
  • 3.10 Is the Applicant listed as an "Additional Insured- Vendor" on the product liability insurance of the 3rd party products they sell?

  • 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
  • NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Applicant's manufacturing operations

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

  • NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Page 4: Product Details

  • Product Categories: Mark all that apply
  • 4.13 Are any products targeted for high value animals?*
  • 4.14 Are any products for livestock or commercially raised animals?*
  • 4.15 Are any products intended for infants or children?*
  • 4.16 Are any products intended for pre-natal or post-natal usage*
  • NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Page 5: Questions about Specific Ingredients

  • Questions about Specific Ingredients

    Enter the percentage of total sales generated by the following ingredients
  • Rows
  • Rows
  • 5.1 Are any products derived from hemp, including hemp-derived CBD?*
  • 5.1b Do any of Applicant's Delta-8 THC, Delta-9 THC, or any other psychoactive substance?*
  • 5.2 Does applicant sell vaping liquids, cartridges, devices, or accessories?*
  • NutriPRO Insurance Application

    NutriPRO Insurance Application

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

  • 6.1 Does the Applicant comply with current Good Manufacturing Practices (cGMPs)?*
  • 6.2 Can the Applicant differentiate its products from those of their competitors?*
  • 6.3 Do the Applicant’s records show when each product was manufactured?*
  • 6.4 Do the Applicant’s records show who each product was sold to, and when?*
  • 6.5 Are the Applicant’s formulas reviewed, tested and verified by outside labs?*
  • 6.6 Are labels, advertisements and warranties reviewed by Legal Counsel to avoid misunderstandings to do with product safety or intended use?*
  • 6.7 Does the Applicant obtain certificates of insurance evidencing Product Liability Insurance from suppliers?*
  • 6.8 Are the Applicant's products formulated, tested, labelled and manufactured to meet or exceed applicable government and industry standards?*
  • 6.9 Have any of the Applicant’s products or ingredients or components thereof, ever been the subject of any investigation enforcement action, or notice of violation of any kind by any government, administrative or regulatory body?*
  • NutriPRO Insurance Application

    NutriPRO Insurance Application

  • Page 7: Regulatory Questions

  • 7.1 Are any of Applicant's products subject to approval by the FDA or any other regulatory body?*
  • 6.11 Are the Applicant’s products or operations subject to any other regulatory approval?
  • 7.2 Is the Applicant familiar with California Proposition 65?*
  • 7.3 Does the Applicant believe their products and product labels are in compliance with California Proposition 65?*
  • 7.4 Is the Applicant aware of any adverse issues or claims involving its products or product labels, related to California Proposition 65?*
  • 7.5 Has the Applicant ever discontinued or is considering discontinuing any products, other than for low sales?*
  • 7.6 Does the Applicant have formal Adverse Event Reporting (AER) procedures in place?*
  • 7.7 Has the Applicant had any Serious Adverse Events (SAEs) in the past 3 years?*
  • 7.7c Have any adverse events resulted in remedial actions?
  • 7.8 Have any of the Applicant’s dietary supplements ever had an active ingredient that would be defined as a drug by the FDA?*
  • 7.9 Does the Applicant have a specific Recall program in place, to withdraw known or suspected defective products from the market?*
  • 7.10 Has the Applicant ever recalled or considered recalling any known or suspected defective products from the market?*
  • 7.11 Is the Applicant aware of any fact or circumstance, which might lead to a product recall?*
  • 7.12 Has the Applicant ever filed for bankruptcy?*
  • 7.13 Are Applicant's business contracts reviewed by an attorney?*
  • 7.14 Are hold harmless and indemnification agreements favorable or mutual?*
  • 7.15  Are guarantees and warranty disclaimers favorable or mutual?*
  • 7.16  Does the Applicant operate a Multi-Level Marketing (MLM) operation?*

  • 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).

  • Date Signed
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  • Should be Empty: