APPLICATION FOR DIETARY SUPPLEMENTS

Instructions to the Applicant:

For any questions answered in “YES”, please provide an explanation on the page titled “EXPLANATIONS”
Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 90 days before the proposed effective date of coverage.
Completion of this application neither binds coverage nor guarantees that a policy will be issued.
Copy of your current products liability insurance declarations page
5‐year company loss runs, valued within the last 60 days

Section I - Applicant Information
Application Name*
List of Any Previous Names or Organizations
Date Established
Proposed Effective Date for this Insurance
Email*
Website
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Additional Locations
Street Address City State / Province / Region ZIP / Postal Code Country
Applicant is
- Corporation
- Partnership
- Joint Venture
- LLC
- Individual
Audit Contact:
Phone Number:*
Section II - Description of Operations
Please describe the nature of your business:
Do you manufacture your own products or products for others?
- Yes
- No
Do you have others manufacture your product(s)
- Yes
- No

If yes, list the manufacturer(s) you use: (NAME AND STATE)*

Section III - Risk Management/Underwriting
1. Has the insured or any insurance carrier of the insured paid any losses or incurred any expenses to defend a claim (i.e., indemnity or expense payments) in the last 5 years?
- Yes
- No
2. 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 agreement?
- Yes
- No
3. Has any insurer declined, cancelled, or non‐renewed any General Liability, Products Liability, or similar insurance on behalf of any person or organization proposed for this insurance?
- Yes
- No
4. Are any of your current or past products in active litigation?
- Yes
- No
5. Have there been any FDA warning letters, consent decrees, FTC actions last three years?
- Yes
- No
6. In the last 12 Months has the applicant had any new product warnings, included but not limited to, black box warning, advisory memorandum or dear doctor letter for safety reasons?
- Yes
- No
7. Does the applicant have any reason to expect that any of the events listed above will occur during the upcoming policy term?
- Yes
- No
8. Have there been criminal charges made against the applicant company or its officers at any point in time?
- Yes
- No
9. Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
- Yes
- No
10. Do you receive “Additional Insured” status from your manufacturing supplier?
- Yes
- No
11. Do the applicant’s products and operations conform to the FDA’s Current Good Manufacturing Practices for Dietary Supplements?
- Yes
- No
12. Have any of your products or ingredients ever been defined as a drug by the FDA?
- Yes
- No
13. Is any of your product revenue attributed to weight loss/increased metabolism, body building/muscle enhancement, or sexual enhancement/dysfunction products?
- Yes
- No
If yes, what percentage
%
Please list those products
14. Are any of the applicant's products principally designed for, approved for and/or marketed to minors or pregnant women?
- Yes
- No
If yes, what percentage
%
Please list those products
15. Has the applicant had any product recalls in the last 3 years?
- Yes
- No
16. Does the applicant anticipate any of the following events in the next 12 months: New Drug Application (NDA) approval, Abbreviated New Drug Application (ANDA) approval, Device Notification (510(k)), Premarket Approval (PMA) decision, acquisition of new product or product line, acquisition of any new company or companies?
- Yes
- No
If yes, provide details
17. Does the applicant's product portfolio include FDA (or foreign equivalent) regulated pharmaceuticals or medical devices?
- Yes
- No
18. Do any of your labels make specific health claims?
- Yes
- No
19. Do you sell any product(s) other than dietary supplements?
- Yes
- No
If yes, what percentage
Please list those products
20. List any past, present, or planned association with any of the following or any derivative of the following – Indicate 0 if none:
Estimated Sales
Androstenedione
Aristolochia
Cascara sagrada
Colloidal Silver
DHEA
Gamma Hydroxy Butrate
Germanium
Jin Bu Huan
Lobelia
Synephrine
Steroids
Aegeline
Opiates/Opioids
DMAA
Animal derived products
Bitter Orange
Chaparral
Comfrey
Ephedra
Germander
Hormone Replacement Therapy
Kava
Magnolia
Sildenafil, tadalafil, vardenafil
Yohimbe
Kratom
DMBA
Section IV - Insurance and Exposure
Projected Gross revenue for upcoming 12 months: $
US Revenue
Foreign Revenue $
Gross revenue for current year: $
US Revenue
Foreign Revenue $
Gross revenue for previous year: $
US Revenue
Foreign Revenue $
Provide the following information for those products, goods and/or services the Applicant wants coverage for
1. Product
1. Year(s) in Market
1. % of Gross Sales
2. Product
2. Year(s) in Market
2. % of Gross Sales
3. Product
3. Year(s) in Market
3. % of Gross Sales
4. Product
4. Year(s) in Market
4. % of Gross Sales
5. Product
5. Year(s) in Market
5. % of Gross Sales
Additional Information
Provide the following historical insurance information for the prior five (5) years:
1. Year
1. Limits of Liability
1. Deductible/SIR
1. Premium
1. Effective Dates
1. Retroactive Date
2. Year
2. Limits of Liability
2. Deductible/SIR
2. Premium
2. Effective Dates
2. Retroactive Date
3. Year
3. Limits of Liability
3. Deductible/SIR
3. Premium
3. Effective Dates
3. Retroactive Date
Indicate the limits of liability and deductible requested:
General Liability (incl products) limit requested: $
If Product Liability ONLY is wanted, list limit requested: $
Deductible requested: $
Indicate current retroactive date:
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 an 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.

WARRANTY
I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.

Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, principals, partners, directors, officers and employees.

Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective date).
Applicant*
Title:
Applicant's Signature*
Date*
Agent / Broker Name
Notice to Applicants: 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 the person to criminal and civil penalties.
Certificate of Insurance Attach
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APPLICATION FOR DIETARY SUPPLEMENTS

Section I - Applicant Information

Section II - Description of Operations

Section III - Risk Management/Underwriting

Section IV - Insurance and Exposure