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Life-Sciences-Renewal-Application-1 - Life Sciences Renewal Application

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  • 25 other fields

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Page1of2
LifeSciencesRenewalApplication
InstructionstotheApplicant–pleasecompletethisapplicationininkandanswerallquestionscompletely.Attachextrasheetsasnecessaryshould
yourunoutofspaceprovided.Anincompleteorillegibleapplicationcannotbeprocessed.Completionofthisapplicationneitherbindscoverage
norguaranteesthatapolicywillbeissued.
Provideafullycompletedapplication,signedanddatedbytheowner,partner,orofficernotearlierthan45daysbeforetheproposedeffective
dateofcoverage.Ifaquestionisnotapplicable,thenstate“N/A”.
Thefollowinginformationmustbesubmittedwiththecompletedapplication:
‐ Copyofyourlabels,brochuresandmarketingfornewproducts,orservices
‐ Copyofyourcurrentfinancialstatementincludingbalancesheetandincomestatement
‐ 5‐yearcompanylossruns,valuedwithinthelast60days
GENERALINFORMATION
ApplicantName(s):__________________________________________________________________________________________
ListofAnyNewlyAcquiredNamesorOrganizations:______________________________________________________________
MailingAddress:____________________________________________________________________________________________
ListAnyNewLocations:______________________________________________________________________________________
AuditContact:_______________________________ PhoneNumber:_________________________________________
RENEWALINFORMATION
1. AnnualSales
GrossSales
–
UnitedStates GrossSales
–
Foreign TotalGrossSales
UpcomingYear
________________________ ________________________ ________________________
CurrentYear
________________________ ________________________ ________________________
2. Haveyoudiscontinuedorareyouconsideringdiscontinuinganyproductorservice: Yes
No
IfYes,providedetails.
3. Haveyouadded,orareyoupresentlyconsideringintroducing,anynewproductorservice? Yes No
IfYes,providedetails.
4. Haveyou,anyofyourproductsoranyofyouringredientseverbeenthesubjectofany Yes No
investigation,enforcementaction,ornoticeofviolationofanykindbyanygovernmental,
administrativeorregulatorybodyincludingtheFDAorFTC?
IfYes,providedetails. __
5. Haveyouvoluntarilyorinvoluntarilyrecalled,orareyouconsideringrecalling,anyknown Yes No
orsuspecteddefectiveproductsfromthemarket?
IfYes,providedetails.____________________________________
______________________________________________________________________________________
6. HaveanyofyourproductsoringredientseverbeendefinedasadrugbytheFDA? Yes
No
7. ProvidethedateofanyFDAinspectionsinthelast18months._________________________________
_

WereyouissuedaFDA483form?
Ifyes,pleaseattachtheformandyourresponse.
Yes No
LOSSHISTORY
1. Isanypersonororganizationproposedforthisinsuranceawareofanyfact,incident,circumstance,
situation,condition,defectorsuspecteddefectwhichmayresultinaclaim,suchthatwouldfallunderthe
proposedinsurance?
Yes No
2. Howmanyadverseeventshavebeenreportedtoyouand/ortheFDAconcerningyourproductsinthelast18months?
Pleaseprovidedetails.
3. Howmanycustomercomplaintshaveyoureceivedconcerningyourproductsinthelast18months?
Pleaseprovidedetails. ____________________________________________________________________________________
KinsaleInsuranceCompany
P.O.Box17008
Richmond,VA23226
(804)289‐1300
www.kinsaleins.com
Page2of2
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mayinclude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tothe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.
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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Life-Sciences-Renewal-Application-1 - Life Sciences Renewal Application

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Completed 2 July 2020

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