Fillable KINSALE ML Cannabis Supplemental Renewal Application (Kinsale Insurance)

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KINSALE ML Cannabis Supplemental Renewal Application (Kinsale Insurance)

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The KINSALE ML Cannabis Supplemental Renewal Application (Kinsale Insurance) form is 6 pages long and contains:

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  • 54 check-boxes
  • 120 other fields

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Page 1 of 6
MANAGEMENT LIABILITY
CANNABIS BUSINESS RENEWAL APPLICATION
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
• Most Recent Financials including any Proformas (if not included with the Business Plan)
• Current Ownership and Organizational Chart
• Current Executive and Board List
Full name of applicant:
Address:
City: State: Zip Code:
Number of locations:
Website:
Available Coverage Section
Limit of
Insurance
Each Claim
Limit of
Insurance
Aggregate
Separate or
Shared
Limits of
Insurance
Deductible
Retroactive
Date
Prior or Pending
Litigation Date
Directors & Officers Liability
Coverage
Employment Practices Liability
Coverage
Fiduciary Liability Coverage
REQUIRED ATTACHMENTS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
1) Type of enterprise: For Profit Nonprofit
2) Years of Operation:
3) Please check what operations the applicant is engaging in:
Recreational Marijuana Growing Patient Care/Physicians on Staff Recreational Marijuana Processing
Medical Marijuana Growing Product Delivery (patients) Medical Marijuana Processing
Recreational Marijuana Retailing Product Delivery (wholesale) Marijuana Laboratory Testing
Medical Marijuana Dispensing Industrial Hemp CDB (cannabinoid) Goods Manufacturing
Other: _____________________________________________________________________________________
Name of
Subsidiary/Entity
Business
Type/Operations
% of Ownership
Date Acquired or
Created
Private Co. or
Nonprofit Org.
5) Please list any other entities and the relationship to the applicant requesting coverage under the policy:
1. Please provide the following financial information for the Applicant and its Subsidiaries. Information must be based on the
most recent audited financials or interim financials if audited financials are not available.
a) Please provide the following Financial Information for the Applicant and its Subsidiaries:
Based on Financial Statements Dated: (Year/Month)
Current Assets $___________________________________________
FINANCIAL INFORMATION
Page 3 of 6
Total Assets $
Current Liabilities $__________________________________________
Total Liabilities $
Total Revenue/Income $ Estimated Revenue next 12 months $
□ Net Income □ Net Loss $
Cash flow from operations $
2. Has the applicant raised capital through any offerings, private placements or other in the last 12 months, or anticipating
within the next 12 months? If Yes, please provide detail:
3. Stock Ownership / total number of voting shareholders:
Director/Officer Shareholders
% of Voting
Shared Owned:
Others owning 10% or more:
% of Voting
Shares Owned:
(Please list any additional shareholders on a separate attachment.)
ILITY (Complete only if applying for this coverage)
EMPLOYMENT PRACTICES LIABILITY (Complete only if applying for this coverage)
1. Employee Count: Full Time ________ Part Time _________ Independent Contractors ______________
a. Does the Applicant have written employment agreements with all officers? Yes No
b. Have the Applicant’s managers and/or supervisors attended training and education programs/ Yes No
seminars on sexual harassment and other types of discrimination within the last 12 months?
If Yes, who has attended?__________________________________________________________
If Yes, who conducts the sessions?___________________________________________________
c. Does the Applicant have its employment policies/procedures reviewed by labor or employment Yes No
counsel?
If Yes, identify the firm and date of last review:
d. Does the Applicant have a Human Resources or Personnel Department? Yes No
If No, who handles this function?____________________________________________________
e. Does the Applicant have an employee handbook? Yes No
If Yes, does the Applicant distribute it to all employees? Yes No
If Yes, do all employees sign up for its receipt? Yes No
If Yes, does it expressly state that it is not a contract and that employment is “at will”? Yes No
f. Does the Applicant have written procedures for handling employee complaints of discrimination Yes No
and/or sexual harassment?
g. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources? Yes No
Outside counsel? Yes No
h. Does the Applicant maintain a personnel file for each employee? Yes No
Page 4 of 6
1. During the past five years, has any insurer ever canceled or non-renewed similar insurance Yes No
with any applicant, or has your insurance been canceled for nonpayment of premium by any
insurance or finance company?
If Yes, please explain.
2. After inquiry with each person as appropriate, in the last five (5) years, have any Directors and Yes No
Officers claims, or any wrongful termination, discrimination, sexual harassment or any other
wrongful employment practices liability claim or suit, including third party claims, or any Fiduciary claims ever been made
against the Firm or any predecessor firm or any current or former member of the Firm or predecessor firm?
If “Yes,” how many?
FIDUCIARY LIABILITY (Complete only if applying for this coverage)
Full Name of Plan
Total # of Participants
Active Number of
Plan Participants
Total Plan Assets
Type of Plan*
$
$
$
$
Defined Contribution = DC; Defined Benefit = DB; Excess Benefit Plan = EB; Welfare Benefit Plan = WB; Employee Stock
Ownership Plan = ESOP
1. Is any listed Plan a multiemployer or multiple employer plan? Yes No
If Yes, please provide detail and if merger activity is anticipated.
2. Does the Applicant or any Subsidiary utilize a Plan investment manager? Yes No
If so, what % of Plan assets are managed by the manager as defined by ERISA? _________
3. How often are plan guidelines and goals reviewed and/or amended by the fiduciaries? __________
4. Have any plans been spun-off, merged or terminated in the last two years? Yes No
5. Does the Applicant or any Subsidiary expect any reduction in benefits, cessation of benefits,
or increase in costs to the Plan participants as a result of any plan amendment anticipated Yes No
in the next twelve months?
Was any such amendment adopted within the last two years? Yes No
OTHER MATERIAL INFORMATION/LOSS HISTORY
OTHER MATERIAL INFORMATION/LOSS HISTORY
Page 5 of 6
3. After inquiry with each person as appropriate, do you, or any of your partners, officers, Yes No
directors, or employees know of any circumstances, acts, errors, omissions, or any allegations or contentions of any
incident that could result in a Directors and Officers claim, any employment related claim,
Including third party claims, or Fiduciary claims?
If “Yes,” how many?
• Business Plan / Complete Narrative on Operations
• Most Recent Financials including any Proformas (if not included with the Business Plan)
• Capitalization Table
• Organizational Chart
• Executive and Board List
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.
REQUIRED ATTACHMENTS
Page 6 of 6
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.
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:
(Must be signed by a Principal, Partner, or Officer of the Firm)
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE ML Cannabis Supplemental Renewal Application (Kinsale Insurance)

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Completed 18 July 2020

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