PrivateLounge-Cannabis Insurance Application

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ENTER YOUR PROMO CODEoptional
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Desired Effective Date of Policy* This field is required.
Year
Month
Day
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Legal Business Name* This field is required.
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Doing Business Asoptional
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Primary Location* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Does the business operate in additional locations?* This field is required.
YESNO
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Describe Additional Locations* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
Business Phone* This field is required.
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FEIN/Tax ID#
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Authorized Contact* This field is required.
First Name
Last Name
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Business Type* This field is required.
Corporation
Individual
Joint Venture
Partnership
LLC
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Cannabis License* This field is required.
State
Please Select
Please Select
Retail
Cultivator
Processor or Extractor
Manufacturer of Products
Testing Lab
Other
No License
Type of License
License Number
13
Upload a copy of your Cannabis Business Licenseor snap a photo on the next page
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Snap a photo of your License
15
Projected Gross Revenue* This field is required.(next 12 months)
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Which best describes the business operations* This field is required.(select all that apply)
Cultivator
Retail Store/Dispensary
Testing Lab
Manufacturing
Processor
Processor using solvent-based extraction
Warehousing/Storage for others
Other
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Describe your Grow Environment* This field is required.
Indoor
Greenhouse
Outdoor
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Where do you sell your Products* This field is required.
Your Retail Store/Dispensary
Other Retailers
Wholesalers
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Are your products tested by a certified laboratory before sale?* This field is required.
YESNO
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Do you use a "seed to sale" or "track & trace" system?* This field is required.
YESNO
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Provide the name of the certified laboratory* This field is required.
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Why are your products not tested* This field is required.
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Describe the “seed to sale” or “track and trace” system that you use* This field is required.
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Why do you not have a track and trace system* This field is required.
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Has the applicant had any claims in the past 12 months?* This field is required.
YESNO
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Provide a summary of all claims and settlements* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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Please attach LOSS RUNS and/or NO KNOWN LOSS documentexpedites policy issuance
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Add Products Liability?* This field is required.If you sell, make, or distribute products, you need Products Liability Insurance. If your product allegedly hurts someone or damages their property, this coverage will help pay your legal fees, judgment or settlement. Anyone can sue over damage from a product, even if they didn't buy it or use it.
YESNO
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Please describe the Products that you sell
Huge
Large
Normal
Small
Ok
Ok
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Add TRIA coverage?* This field is required.TERRORISM RISK INSURANCE AGREEMENT(TRIA) which was enacted by Congress in November 2002, ensures that adequate resources are available for businesses to recover and rebuild if they are the victims of a terrorist attack. Under TRIA all property/casualty insurers in the U.S. are required to make terrorism coverage available.
YESNO
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Does the applicant hire subcontractors through a third-party source for its cannabis operations?* This field is required.
YESNO
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How much will you spend for all contracted work over the next 12 months?* This field is required.
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Add Additional Insured to your policy?* This field is required.
YESNO
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Additional Insured Information* This field is required.
Name
Address
Please Select
Please Select
Managers or Lessors
Vendors
Mortgagee
Assignee or Receiver
Landlords Leased Land
Designated Person or Organization
Lessor Leased Equipment
Trade Show Sponsor
Relationship
Special wording required for the Certificate of Insurance
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Additional Coverage Options* This field is required.select all that apply
Excess Liability
Commercial Auto
Workers Compensation
Directors & Officers Liability
Cyber Liability
Property
None of the above
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Notes or Comments
Huge
Large
Normal
Small
Ok
Ok
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Please verify that you are human* This field is required.
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Print your Name* This field is required.
First Name
Last Name
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Email Contact* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
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Signature* This field is required.
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AgencyCA License #6012385
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Agency Email
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