Fillable PR GC E Cig Tobacco Supplemental Application (Kinsale Insurance)

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PR GC E Cig Tobacco Supplemental Application (Kinsale Insurance)

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The PR GC E Cig Tobacco Supplemental Application (Kinsale Insurance) form is 5 pages long and contains:

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  • 50 check-boxes
  • 63 other fields

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Page 1 of 5
ELECTRONIC CIGARETTE AND TOBACCO 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:
Brokerage/Broker:
Agency/Agent:
Renewal? Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal? Yes No
Claims made? Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five-year loss runs, including claim detail for all losses open or exceeding $15,000
b) Applicant’s product brochure, catalog, or marketing materials if a website is not available
c) Current policy declarations page for retroactive date and limits recognition (if applicable)
3) What business operations are you engaged in? Check all that apply:
Manufacturing/Import of Vaporizers Manufacturing/Import of Cigarettes/Cigars
Manufacturing/Import of eLiquids Manufacturing/Import of Hookah Tobacco
Manufacturing/Import of eLiquid Ingredients Manufacturing/Import of Other Tobacco
Manufacturing/Import of Non-Electronic pipes Manufacturing/Import of Tobacco Alternative Products
Manufacturing/Import of Self-Contained Disposable Electronic Cigarettes
Manufacturing/Import of Smoking Accessories Not Otherwise Described Above
Tobacco/Electronic Cigarette Distribution (must be from a domestic manufacturer granting applicant Additional Insured status)
Tobacco Shop/Smoke Shop Electronic Cigarette Shop
Electronic Cigarette or Tobacco/Smoke Shop with CBD/Cannibidiol Sales
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
4) Mailing address:
Address:
City: State: Zip Code:
5) Premise address:
Address:
City: State: Zip Code:
6) Total Sales for coming year:
7) For eLiquid/Vape Juice, please check all ingredients used:
Vegetable Glycerin Nicotine Other
Propylene Gylcol Water
Natural Flavorings Alcohol
Artificial Flavorings CBD/Cannibidiol
a. If “Other” is checked above, please clarify:
b. Are all flavorings free from diacetyl (butanedione or butane-2,3-dione)? Yes No
c. Are all liquids free from vitamin E acetate (α-Tocopheryl acetate or synthetic vitamin E)? Yes No
d. Are all ingredients FDA food grade as applicable? Yes No
8) For Tobacco Products, please check all ingredients used:
Vegetable Glycerin Leaf Tobacco
Honey/Molasses Spent Sugar Cane Husk (for non-tobacco hookah shisha)
Natural Flavorings Porous Stone (for non-tobacco hookah shisha)
Artificial Flavorings Other
a. If “Other” is checked above, please clarify:
b. Are all flavorings free from diacetyl (butanedione or butane-2,3-dione)? Yes No
9) If you sell any products containing CBD, what percentage of sales are of these products? %
10) If you have wholesale and retail sales, what percentage is retail to consumer? %
11) How can your products be differentiated from those of your competitors?
12) What independent 3
rd
party testing is done on products?
13) What destructive safety testing is done on electronic cigarette batteries and chargers manufactured or sold by you?
14) Are chargers designed to shut off once a battery has completed charging or overheating Yes No
is detected?
15) Do you have ISO 9001, FDA, CE, and/or UL Certification? Yes No
Please list Certifications:
Page 3 of 5
16) If operating a retail storefront, does your shop contain a lounge area where patrons may smoke Yes No
or “vape” on premise?
a. If Yes, is entry to the store strictly limited to patrons over 18 years of age? Yes No
b. If Yes, are any foods or beverages sold or provided complementary? Yes No
Please describe:
17) Are there any present situations that might give rise to an incident causing a product recall? Yes No
If Yes, supply details.
18) Have you had any Product Liability claims that were or were not covered by insurance? Yes No
If Yes, please provide details.
19) Have you been cited by any regulatory agency for violations arising out of business Yes No
activity involving your product?
If Yes, provide details.
20) Have you declared bankruptcy in the last ten years? Yes No
If Yes, please explain:
21) Do you have any discontinued products? Yes No
If Yes, please explain the reasons for discontinuing.
22) Do you rent your premises? Yes No
If yes, does your landlord require Additional Insured status in your written rental/lease Yes No
agreement?
23) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company?
If Yes, please explain.
24) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages or accidents (including but not limited to allegations of faulty or defective products,
product failure, product dispute bodily injury or property damage) arising out of or related to
your products that a reasonably prudent person might expect to give rise to a claim or lawsuit
whether valid or not which might directly or indirectly involve the company?
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
Page 4 of 5
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.
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.
Page 5 of 5
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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PR GC E Cig Tobacco Supplemental Application (Kinsale Insurance)

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Completed 15 July 2020

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