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General Liability and Excess Cannabis


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

First Name of Contact Person
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Last Name of Contact Person
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Street
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City
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State / Province
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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Business Legal Name
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First Name
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Last Name
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DBA
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Entity Type
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Type of Opeeration
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Description of Operation
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Other Type of Operation
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Cannabis Use
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Projected Revenue for the next 12 months
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Past 12 months of Revenue
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In Business How Long
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Liability Coverage Options
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Deductible
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If you selected "More" then how much Coverage
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If you select "More" for the Deductible please define a number more than$25,000
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Any Regulatory Actions
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Stop Gap Coverage
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Auto Included
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Has your insurance ever been canceled?
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Do you currently have insurance?
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If Yes, who is your insurer
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Any claims in the past 5 years
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If yes, then please give details in comment box
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Has any of the owners or employees been convicted to trafficking violations in the past 10 years
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Is your entity currently licensed for cannabis?
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Building and Structure Address
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Is your location open and operational?
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Describe structure / building
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Hours of Operation
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How old is the building structure you operate out of?
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If the building is over 20 years old, please provide any renovations
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Describe Renovations
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Building /Structure Construction Type
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Number of stores on building/structure
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Building/ structure have sprinkler system
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Is there residential area within 100 yards of your facility?
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Is your facility being operated out of your residence
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Any dogs on premises
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If there is a dog on premises is there signage posted
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Is there a Central Stage Alarm system functioning at the facility?
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Is there a safe at the facility?
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If yes, what is the weight of the safe
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Fire Rating of Safe
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Do you use a vault to safe guard inventory?
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Is there a buzz in system or security personnel at your facility? Optional
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Does the facility have security cameras?
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Does the facility have firearms on site?
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Describe Security Guards
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Seed to Sale Tracking System
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What is the name of the system?
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Additional Insured
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Additional Insured Address
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Do you want to decline property coverage at this time?
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Building Coverage Value
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Loss of Income Value per month
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Outdoor Signs ?
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Cannabis Inventory Dollars Value
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Other Inventory Dollar Value
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Indoor Grown? %
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Greenhouse Grown?
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Outdoor Grown? %
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Greenhouse Grown? %
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Dollar Value of Indoor Grow Equipment
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Business/Personal Property Dollar Value
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Tenant Improvement Dollar Value
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Do you wish to add Property and Equipment in the event of loss or breakdown?
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Transport of inventory Add Coverage
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Employee Theft
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Cultivation on site
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How many cultivation structures do you have at this location
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Grow Operation Percentage
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If other, please specify
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Equipment for grow operation
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How many harvests per year?
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Seeds Coverage Total Value Per Harvest
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Immature Seedlings Value Per Harvest
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Vegetative Plant value per harvest
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Flowering Plant value per harvest
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Harvested Plant value per harvest
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Finished Stock value per harvest
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Please warrant the following
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I confirm and warrant that the aforementioned is true
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Manufactured Products List
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List of Vendors Covered
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Do you repackage any products?
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If yes, please specify
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Have you had any products recalled in the past 2 years
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If yes, please specify
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New product coming out in the next 12 months
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Quality Control/ Loss Control
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Any claims in the past 5 years
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If yes, please specify
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I have read the disclaimer forms
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Any Investor Question Please Call Hayden IR 917-658-7878

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