Fillable CP Cannabis Property Supplemental (Kinsale Insurance)

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CP Cannabis Property Supplemental (Kinsale Insurance)

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The CP Cannabis Property Supplemental (Kinsale Insurance) form is 5 pages long and contains:

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Page 1 of 5
CANNABIS PROPERTY SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
New: Yes No
Renewal: Yes No Policy Number:
Effective Date:
Website:
Years in Operation:
Please attach:
Currently valued five year loss runs and, if applicable, claim details
Completed SOV Form for all locations
Location photographs
2) Mailing address:
Address:
City: State: ______ Zip Code: ______ __
3) Schedule of Locations:
Location #1:
Address:
City: __________________________________ State: ______ Zip Code: ________ Date Owned:_________________
Location #2:
Address:
City: __________________________________ State: ______ Zip Code: ________ Date Owned:_________________
Location #3:
Address:
City: __________________________________ State: ______ Zip Code: ________ Date Owned:_________________
Location #4:
Address:
City: __________________________________ State: ______ Zip Code: ________ Date Owned:_________________
4) Operations:
Growing – Indoors Processing – Utilizing Pressure, Heat, or Baking/Cooking
Growing – Greenhouse Processing – Supercritical or Solvent Extraction
Retail/Dispensary Processing – Solventless, No Heat or Pressure
Lessors’ Risk Only (attach document of tenant entity names and operations)
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
Indicate Yes (Y) or No (N) for all security measures:
Location 1
Location 2
Location 3
Sprinkler System
Central Station Fire Alarm
Central Station Burglar Alarm
24/7 Interior and Exterior Video Surveillance with minimum 14-day
video feed storage
Interior motion detectors
Entryways, doors, windows locked, secured and protected by alarm
during non-business hours
Buzz-in system at entryway
Building Gated and fenced
Doors and windows equipped with shatter proof glass
Security Guards
Safe* or Vault
*All finished stock inventory is kept locked in a safe at all times
during non-business hours. If safe used to house all marijuana stock
and/or inventory is less than 2,000 pounds it will be bolted to the
ground and have a one hour fire rating.
5) Will you be doing any renovations, construction, or improvements or betterments Yes No
to the property before occupation?
a. If yes, will a licensed contractor be performing the work? Yes No
b. Are certificates of insurance obtained from contractors or subcontractors Yes No
before completing the work?
c. Will work be structural in nature? Yes No
d. Estimated cost of work: $
6) Do you have a state license in your own business name for cannabis operations? Yes No
a. If no, are operations strictly limited to hemp cannabis (under 0.3% THC)? Yes No
b. If operations are not hemp only and you are unlicensed, please clarify:
7) Do growing operations occur in a greenhouse (in part or whole)? Yes No
If yes, please describe frame type and covering material(s):
SECTION B: SECURITY MEASURES
SECTION C: GROWING
Page 3 of 5
8) Do you utilize any hydroponics, aeroponics, or automated watering systems? Yes No
If Yes, please describe automated shutoff/anti-flood measures in place:
9) Has the electrical system been upgraded for your occupancy of the building? Yes No
If yes, please describe:
10) Describe the type of lighting used:
11) Do you utilize CO
2
generator, Ozone generator, Humidifier/Dehumidifier, or other Yes No
environmental conditioner equipment (not including normal HVAC)?
If yes, please describe:
12) Do you have a backup power generator? Yes No
13) Are you performing any solvent extraction? Yes No
a. If yes, please list solvents used:
b. If solvent extraction is not closed loop only, please clarify:
14) If Butane, Hexane, Propane or other volatile extraction is performed, confirm the following measures are in place:
a. All extraction work carried out in Class 1 D1 Room(s) Yes No
b. Automatic exhaust ventilation system Yes No
c. Sprinklers Yes No
d. Explosion proof electrical system Yes No
e. Automatic gas detection system Yes No
f. Sprinklers in fume hoods Yes No
15) If gasses or flammables are stored on site:
a. Are all gas cylinders stored in approved cages on an external wall? Yes No
b. Types and quantities of gas stored:
c. Are all flammables stored in UL listed cabinet(s)? Yes No
d. Types and quantities of flammables stored:
16) Are all utensils used in extraction process non-sparking? Yes No
17) Are you cooking, baking, or otherwise preparing edibles or extracts using heat? Yes No
If yes, are all cooking areas equipped with Ansul or UL compliant Yes No
automatic fire extinguishing systems above all cooking surfaces, hoods
and duct area, with a quarterly maintenance service contract in place?
SECTION D: PROCESSING
Page 4 of 5
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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.
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.
Page 5 of 5
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.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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CP Cannabis Property Supplemental (Kinsale Insurance)

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Completed 18 July 2020

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