Fillable Cannabis Testing Lab Application JamesRiverInsuranceCompany anditsSubsidiaries (Special Risks)

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Cannabis Testing Lab Application JamesRiverInsuranceCompany anditsSubsidiaries (Special Risks)

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JamesRiverInsuranceCompany
anditsSubsidiaries
6641WestBroadStreet,Suite300
Richmond,VA23230
Cannabis Testing Lab Application
LIFESCIENCES
Division
APPLICANT’SINSTRUCTIONS:
1. Answerallquestionscompletely.Pleaseattachextrasheetsasrequired.Incompleteorillegibleapplicationsmaybediscarded.
2. Applicationmustbesignedanddatedbytheowner,partner,orofficernotearlierthan90daysbeforetheproposedeffectivedateofcoverage.
3. Pleasereadthestatementsattheendofthisapplicationcarefully.Thankyou!
NOTICE:Thepolicyprovidesthatthelimitsofliabilityavailabletopayjudgmentsorsettlementsshallbereducedbydefenseexpenses,andthat
defenseexpensesshallbeappliedagainstthedeductibleamount.
FormJRAP0200 Page1of5 ©JamesRiverInsuranceCo.2019
SECTIONI–GENERALINFORMATION
Applicantname:
DBA:
Address:
City: State: Zip:
Phone: Website:
Yearsinbusinessundercurrentmanagement: Dateestablished:
Inspectioncontactnameandinformation:
Typeofenterprise: Corporation Individual Partnership Proprietorship
Non‐profit Forprofit Jointventure
Other:
Descriptionofoperations:
Listofsubsidiariesandtheiroperations:
Listanyadditionalofficesandprovidelocations:
Haveanyoftheprincipalsengagedinthisorsimilarenterprisesunderadifferentname? Yes No
If“Yes”,pleaselistentityandoperations:
Providebusinessfinancialinformationforthelastfive(5)yearsandestimatesforthenextyear:
Year Domesticrevenues Foreignrevenues Payroll #ofemployees
Nextyear
Lastyear
2
nd
yearprior
3
rd
yearprior
4
th
yearprior
5
th
yearprior
FormJRAP0200 Page2of5 ©JamesRiverInsuranceCo.2019
SECTIONII–QUESTIONS
1. Descriptionofproductstested(checkallthatapply):
MedicalMarijuana
RecreationalMarijuana
Hemp/CBD
Non‐cannabisProducts. Ifcheckedwhatisthepercentageofoperations:%
Non‐producttesting(e.g.environmentalsoiltesting,etc)
2. Iftheapplicanttestsbothmarijuanaandhemp,pleasedescribewhatmethodsareusedtoseparatethemarijuanatesting
fromthehemp/CBDtesting:
3. Iftheinsuredhasanyoperationsthatarenotcannabisproducttesting,pleasedescribe:
a. Describewhatmethodsareusedtoseparatethecannabisproducttestingfromtheoperationsdescribedabove:
b. Doestheapplicanthaveinsuranceforalloperationsdescribedabove?
Yes No
c. Whatcoverageandminimumlimitsareinplacefortheoperationsdescribedabove?
4. Describetheareainwhichtheapplicant’sbusinessislocated:
Commercial Industrial Agricultural Residential
5. Isthenatureofthebusinessadvertisedontheoutsideofthebuilding? Yes No
6. Doesapplicantoccupytheentirebuilding? Yes No
If“No”,arethereconnectingdoorstoadjacentunits?
Yes No
a. Howaretheconnectingdoorssecured:
7. Whichofthefollowingsecuritysystemsareutilized(pleasecheckallthatapply):
Employeebadges
Accesscodes
Designatedlimited‐accessareas
Vault/safe
Gatedwindows
Panicbutton
Guards‐unarmed
Guards‐armed
Interior24‐hourvideosurveillance
CentralStationAlarm
Gateddoors
8. Ifguardsareused,aretheyemployees? Yes No
If“No”,doindependentcontractorsactingassecurityguardscarrytheirowninsurance?
Yes No
a. Doestheapplicantgetcertificatesofinsurance(COIs)evidencinglimitsandAIstatusfortheapplicant?
Yes No
b. Whatminimumlimitsofcoveragedoindependentcontractorscarry?
9. Doestheapplicanthaveownershipinanyothercannabisbusinessinadditiontothetestinglab? Yes No
10. Whatexperiencedoestheapplicanthaveinoperatingatestinglaboratoryand/oroperatingacannabisbusiness?
Pleasedescribe:
11. IsthelabISO17025accredited? Yes No
12. Doestheapplicanthaveanystateorlocalgovernmentlicenses,permits,oraccreditations? Yes No
If“Yes”,pleasedescribe:
FormJRAP0200 Page3of5 ©JamesRiverInsuranceCo.2019
13. Doestheapplicantconducttestsforanyofthefollowing(checkallthatapply)?
Pesticides
Bacteria
Mold/fungus
Mycotoxins
Heavymetals
Residualsolvents
Cannabinoidprofiles(e.g.THCA,delta8‐THC,delta9‐THC,CBDA,CBD,CBG,CBN,etc.)
Potencyperserving
THCpercentage
TerpeneProfiles
Other:
14. DoestheapplicanthaveSOP’sinplacefor:
a. Sampling
Yes No
b. LaboratoryProcesses
Yes No
15. Doestheapplicanthaveasamplefieldlog? Yes No
16. Doestheapplicanthaveawrittenchainofcustodyprotocol? Yes No
17. Doestheapplicantrequireallsamplescomewithachainofcustodyform? Yes No
18. Doestheapplicant’stestingmethodsincludeanyofthefollowingguidelines(checkallthatapply)
FDABacterialAnalyticalManual
AOACInternationalOfficialMethodsofAnalysisforContaminantTestingofAOACInternational
USPharmacopoeiaandtheNationalFormulary’sMethodsofAnalysisforContaminantTesting
FDAGuidelinesfortheValidationofMethodsfortheDetectionofMicrobialPathogeninFoodsandFeeds
FDAGuidelinesfortheValidationofChemicalMethodsfortheFDAFVMProgram
CannabisInflorescence:StandardsofIdentify,Analysis,andQualityControlmonographpublished
bytheAmericanHerbalPharmacopoeia.
LaboratoryoperationsfromtheAmericanHerbalProductAssociation
AOACInternational’sOfficialMethodsofAnalysisforContaminantTestingofAOACInternational
OECDPrinciplesofGoodLaboratoryPracticeandComplianceMonitoringpublishedbythe
OrganizationforEconomicCo‐operationandDevelopment
Other–pleaseexplain:

19. Doestheapplicantusecertifiedreferencematerialstovalidatetestmethods? Yes No
20. Doestheapplicantmaintainwrittenrecordsoflot/batchnumbersusedtoidentifybatches? Yes No
21. Doestheapplicantretainsamplesoftestedproducts? Yes No
22. DoestheapplicanthaveaLaboratoryQualityAssuranceProgram? Yes No
23. Doestheapplicantparticipateinproficiencytesting? Yes No
24. DoestheapplicantconductannualinternalauditsonSOPsandLQA? Yes No
25. Hastheapplicanteverfailedanygovernmentaudits? Yes No
If“Yes”,pleaseexplain:
26. Doestheapplicantuseanattorneyreviewedagreementwithallcustomers? Yes No
27. Doesapplicant’sagreement(s)containthefollowingprovisions(checkallthatapply)?
Alldutiesandresponsibilitiesofeachparty
Holdharmlessagreements/indemnificationprovisions
Limitationofliabilities
Warrantiesandrepresentation
FormJRAP0200 Page4of5 ©JamesRiverInsuranceCo.2019
28. Doestheap
plicantusethefollowingtesting(checkallthatapply)?:
LC‐MS
GC‐MS
HPLC‐MS
NMR
Other‐pleaseexplain:
29. Whoperformsthecalibrationofequipment?
30. Whoperformsservice/maintenanceofequipment?
31. Arelogskeptofallservicing,maintenance,andcalibrationofprecisioninstruments? Yes No
32. Doestheapplicanthaveawrittenemployeetrainingprogram? Yes No
33. Describetheeducationalandexperientialbackgroundofthefollowingemployees.Includehighestdegree
achieved,subject,andyearsofrelevantexperience:
a. Supervisory/management
b. Analyst
c. Sampler
34. Ifanyservicesaresubcontracted,doestheapplicantobtainthefollowing:
a. Awrittencontractcontainingaholdharmless/indemnificationprovisionintheinsured’sfavor
Yes No
b. Acertificateofinsurance(COI)evidencingproducts/completedoperationscoverageand
AIstatusfortheinsured
Yes No
SECTIONIV–SIGNATURE,CONSENTANDAGREEMENT
ThisApplicationisthebasisforcoverage;therefore,anyincorrectorincompletestatementsoranswerscouldnullifycoverage.Completionofthis
formneitherbindscoveragenorguaranteesthatapolicywillbeissued.(NotapplicableinNorthCarolina)
Iherebyrequestthatmyapplicationforinsurancecoveragebesubmittedforconsiderationtothecompanyshowninthisapplication.Accordingly,I
authorizeanddirectanypersonororganizationwhatsoevertoreleaseandfurnishtothatcompanyanyandallinformationrequestedwhichmay
relatetomyinsurability.
Iherebyindicatethattheaforementionedstatementsandanswersarecorrectandcomplete.Ifurtherunderstandthatanincorrectorincomplete
statementoranswercouldvoidmyprotection.
Iherebyconsenttothereviewbythecompanyshowninthisapplicationofanyincidentsoroccurrenceslikelytoresultinmalpracticeallegationor
claim.Iagreetocooperateinthereviewofclaimsandincidentswhichapplytothecoveragerequested.
Whereapplicable,Iherebyconsenttothereviewofmyapplicationbythecommitteesappointedbymycountyorstateprofessionalassociation/
society.Iagreetocooperatewiththesecommittees.
SECTION III – PRIOR INSURANCE AND CLAIMS HISTORY
1. Please provide insurance information for the past three (3) years.
Carrier Limits Deductible Retro date Premium
Exposure base or
policy rate
2. In the last five (5) years, has any claim been made against any person(s) or organization(s) to be covered
Yes No under this insurance?
If “Yes”, please provide five (5) year loss history for all claims below and attach a description for any
loss greater than $10,000:
Year # of claims Total paid Total reserves Total incurred Valuation date
FormJRAP0200 Page5of5 ©JamesRiverInsuranceCo.2019
FRAUDSTATEMENTS
ApplicableinAL,AR,DC,LA,MD,NM,RIandWV
Anypersonwhoknowingly(orwillfully)*presentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowingly(orwillfully)*presents
falseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.*AppliesinMDOnly.
ApplicableinCO
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FLandOK
Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementofclaimoranapplicationcontainingfalse,
incomplete,ormisleadinginformationisguiltyofafelony(ofthethirddegree)*.*AppliesinFLOnly.
ApplicableinKS
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KY,NY,OHandPA
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concealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsa
fraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties*(nottoexceedfivethousanddollarsandthestated
valueoftheclaimforeachsuchviolation)*.*AppliesinNYOnly.
ApplicableinME,TN,VAandWA
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anddenialofinsurancebenefits.*AppliesinMEOnly.
ApplicableinNJ
Anypersonwhoincludesanyfalseormisleadinginformationonanapplicationforaninsurancepolicyissubjecttocriminalandcivilpenalties.
ApplicableinOR
Anypersonwhoknowinglyandwithintenttodefraudorsolicitanothertodefraudtheinsurerbysubmittinganapplicationcontainingafalse
statementastoanymaterialfactmaybeviolatingstatelaw.
Ihavereadthestatementsabove,understandtheirmeaningandagree.
Applicant’ssignature:
Date:
Applicant’sname:
Applicant’stitle:
NOTICETOAPPLICANT
Thecoverageappliedforissolelyasstatedinthepolicy.Ifpolicyisissuedona"CLAIMSMADE"or“CLAIMSMADEANDREPORTED”basis,itprovides
coverageonlyforthoseclaimsthatarefirstmadeagainsttheinsuredduringthepolicyperiodunlesstheextendedreportingperiodoptionis
exercisedinaccordancewiththetermsofthepolicy.Ifissuedonan“OCCURRENCE”basis,thepolicyprovidescoverageonlyforthoseoccurrences
thattakeplaceduringthepolicyperiod.
TheInsurerwillrelyuponthisapplicationandallsuchattachmentsinissuingthepolicy.Iftheinformationinthisapplicationoranyattachment
materiallychangesbetweenthedatethisapplicationissignedandtheeffectivedateofthepolicy,theApplicantwillpromptlynotifytheInsurer,who
maymodifyorwithdrawanyoutstandingquotationoragreementtobindcoverage.
COPYOFNOTICEOFINFORMATIONPRACTICES(PRIVACY)HASBEENGIVENTOTHEAPPLICANT.
(Notrequiredinallstates,contactyouragentorbrokerforyourstate’srequirements.)
Personalinformationaboutyou,includinginformationfromacreditorotherinvestigativereport,maybecollectedfrompersonsotherthanyouin
connectionwiththisapplicationforinsuranceandsubsequentamendmentsandrenewals.Suchinformationaswellasotherpersonalandprivileged
informationcollectedbyusorouragentsmayincertaincircumstancesbedisclosedtothirdpartieswithoutyourauthorization.Creditscoring
informationmaybeusedtohelpdetermineeitheryoureligibilityforinsuranceorthepremiumyouwillbecharged.Wemayuseathirdpartyin
connectionwiththedevelopmentofyourscore.Youmayhavetherighttoreviewyourpersonalinformationinourfilesandrequestcorrectionofany
inaccuracies.Youmayalsohavetherighttorequestinwritingthatweconsiderextraordinarylifecircumstancesinconnectionwiththedevelopment
ofyourcreditscore.Theserightsmaybelimitedinsomestates.Pleasecontactyouragentorbrokertolearnhowtheserightsmayapplyinyourstate
orforinstructionsonhowtosubmitarequesttousforamoredetaileddescriptionofyourrightsandourpracticesregardingpersonalinformation.
(NotapplicableinAZ,CA,DE,KS,MA,MN,ND,NY,OR,VA,orWV.SpecificACORD38sareavailableforapplicationsinthesestates.)
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Cannabis Testing Lab Application JamesRiverInsuranceCompany anditsSubsidiaries (Special Risks)

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Completed 9 July 2021

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