CALIFORNIA CANNABIS INSURANCE APPLICATION CannabisIns.com Victor Gomez Insurance Agency (209) 581-0970 Instructions: 1. Complete all answers truthfully and completely. (False or concealed information in an application can impair your coverage, so please be as candid as possible!) 2. This application must be signed and dated by the owner, partner, or officer of your cannabis business. 3. Make sure to save this document after completing by using the Save As functionality. I. Applicant ( You Or Your ) Information Applicant Name: Mailing Address: Location Address : Website: Contact Name: Phone #: Applicant business form: Individual/Sole Proprietorship Corporation Partnership LLC Is Applicant operating as a DBA? ; if yes, state DBA: II. License Information* A. Local License or Permit 1. Do you have a license or permit issued by your city or county to engage in the sale, manufacture, or cultivation of cannabis? 2. If yes, provide the following information: Local License/Permit No. Effective Date Expiration Date City or County B. State License 1. Have you applied for or received a license from the State of California to engage in the sale, manufacture, or cultivation of cannabis? 2. If yes, provide the following information: State of CA License No. Effective Date Expiration Date License Type 3. If no, provide the following information: a. I intend to submit my license application to the State of California on: / / b. My Application was submitted to the State of California on: / / c. An Acknowledgement of my Application was received on: / / d. A Temporary State License has been issued as follows: Temporary License No. Effective Date Expiration Date License Type *Notify your insurance agent immediately if your license expires or if your application for a license is denied. Lack of proper licensing may impair your coverage or void your policy. GBC App 001 2017-12-18 1 of 7
III. Coverages A. Check all applicable boxes to indicate the coverages you are requesting: 1. General Liability and Property Only 2. General Liability, Property and Products Liability 3. Include Theft to Property 4. Include Additional Property Coverage: Tier 1 - $500 Tier 2 - $1,000 Tier 3 - $1,500 IV. Cannabis Operations A. Check ALL boxes below that apply to the operations for which you seek coverage: 1. Retail Store/Dispensary 2. Limited Cultivation of cannabis (cannabis grown only to sell in my retail store and not to other licensed cannabis operations) 3. Cultivation of cannabis 4. Manufacturing of cannabis products 5. Distribution of cannabis (warehousing of cannabis only) 6. Transportation (garage for vehicles used in the cannabis distribution cycle) V. Eligibility Criteria A. The following questions must be answered before the Underwriter can proceed 1. Do you have any cannabis operations outside of the State of California? a. If yes, what operations and where: 2. Do you cultivate, manufacture, buy, or sell any cannabis or cannabis products outside of the State of California? 3. Do you run background checks on all employees before hire? 4. Do you sell any products with packaging that may be confused by young children as candy? Maybe; if yes or maybe, what is the product? 5. What percentage of your sales involves e-cigarettes or electronic vaporizers? % 6. If the building is over 20 years old, when were the following upgraded? Roof: Plumbing: Wiring: Sprinklers: HVAC: 7. Does this location have a Central Station Alarm? Yes a. If yes, advise alarm provider: 8. Describe the safe on the premises used for storing cash or product by: Brand: Model: TL Rating: ; is the safe bolted to the structure? 9. Do you have video surveillance of all areas of your operation at all times? a. If yes, is the video retained by the insured for at least 60 days? 10. Do you have a Track and Trace (or similar) software system? VI. Sales 1. What percentage of your sales is: Retail sales: % Mail order sales: % Wholesale sales: % Do you use the US Postal Service? GBC App 001 2017-12-18 2 of 7
VII. General Liability A. LIMITS: General Liability (Excluding Products) Options: $1,000,000 Each Occurrence $500,000 $300,000 $2,000,000 General Aggregate $1,000,000 Personal and Advertising Injury Exclude $100,000 Damage to Premises Rented to You $250,000 $2,500 Medical Payments Exclude EXCLUDED Products/Completed Operations Aggregate Products Liability Options: $1,000,000 Each Occurrence $500,000 $300,000 $2,000,000 Products - Completed Operations Aggregate B. General Liability Rating Information Gross Sales Information: Projected Year Current Year Prior Year Retail Sales (plants/products) $ $ $ Cultivation $ $ $ Manufacturing $ $ $ Other (explain) $ $ $ Total: $ $ $ Payroll Information: Projected Year Current Year Prior Year Distribution/Warehousing $ $ $ Transportation $ $ $ C. Security Rating Information 1. If you hire your security personnel, what is the estimated annual payroll? $ a. Are they armed? 2. If you contract to provide security, what is the estimated annual contract cost? $ a. Are they armed? D. Limited Assault & Battery Coverage requested? 1. If yes, what per Occurrence sub-limit? $ (Maximum of $1,000,000) E. Hired and Non-Owned Auto Liability requested? 1. If yes, does your firm rent vehicles? ; and 2. Do your employees use their own vehicles on company business? VIII. Property A. Coinsurance Statement Property Coinsurance: 80% or %; Business Interruption Coinsurance: 80% or % B. Limits per Location Location 1 Location 2 Location 3 Building or T.I.B. $ $ $ Contents (Business Personal Property) $ $ $ Business Income ($2,000,000 Max) $ $ $ Cannabis Stock ($1,000,000 Max) $ $ $ GBC App 001 2017-12-18 3 of 7
IX. Management Information A. Are you in full compliance with all local and State of California laws that govern the cultivation, manufacture, and sale of cannabis and cannabis products? B. Are you a member of any cannabis/marijuana trade association? 1. If yes, list organizations: C. Do you have prior experience running a business? 1. If yes, describe that experience and state number of years: D. How many years have you been in the Cannabis business? E. Have you implemented procedures to protect patient/patron privacy rights? 1. If yes, describe privacy procedures and staff training procedures: F. Does your operation have an on-site manager at all times? G. Describe your manager s experience: H. How many employees do you employee? I. What is the smallest number of employees ever on site during business hours? J. Do you run background checks on all employees before hire? 1. If yes, please disclose any known history of theft or violent crime: K. State hours of operation: L. Do you have front door security/metal detector? Describe: M. Do you maintain written or electronic records of all cannabis and cannabis products, including the purchase date, type of product, and purchase price? N. Have you or other owners or managers ever been convicted of a felony drug offense or a crime of dishonesty, such as fraud or theft? 1. If yes, state offense and conviction date: X. Contracted Security A. Does the contractor carry GL coverage with limits of $1 million or more? B. Does the security contract hold you harmless? C. Does the contractor s policy name you as an Additional Insured? D. What are the contractor s sub-limits for Assault & Battery Coverage: $ XI. Safety A. Number of patrons allowed into showroom at any time? B. Do you have safety procedures? 1. If yes, describe your procedures: C. Is there any exposure to flammables, explosives, or chemicals at any location? GBC App 001 2017-12-18 4 of 7
XII. Property Information Number of locations to be insured:. Instructions: COMPLETE THIS PAGE 5 FOR EACH LOCATION TO BE INSURED A. Location Information 1. Location Address: 2. Is building owned by you or rented? 3. Describe the building: a. Age: b. Number of stories: c. Square footage of building you occupy for your cannabis operations: d. Construction type: Wood Frame Masonry Concrete Block Concrete Tilt-up Steel Frame 4. If the building is over 20 years old, when were the following upgraded? Roof: Plumbing: Wiring: Sprinklers: HVAC: 5. Other business occupants of building? Describe: 6. Describe all adjoining occupancies: (left, right, and rear): 7. Distance from fire station: Distance from fire hydrant: 8. State the number of windows at the business premise: 9. Describe any window protection, such as bars or roll-down steel doors: 10. Is the building sprinklered? a. If yes, what percentage of the building is sprinklered? % 11. Do you have video surveillance of all areas of your operation at all times? a. If yes, is the video retained by the insured for at least 60 days? b. If no, how long is video retained? B. Cannabis inventory and values at this location: 1. Value the following Cannabis products: Maximum Value % of Total Cannabis Plants/buds $ % Oils and Tinctures $ % Edibles $ % Vape Pens $ % Pipes & other paraphernalia $ % All other products $ % Total Gross Values $ C. Building and Location Information 1. Does any physical feature of the premise create an access impediment for first responders? (For example, is your premise entry on a second floor?) If so, describe: 2. Is the business premise wheelchair accessible? 3. Do you occupy the entire building? GBC App 001 2017-12-18 5 of 7
XIII. Additional Information Complete only those Sections that apply to You. A. Retail Stores 1. Is cannabis stock in locked display cases, refrigerators, or a vault at all times? 2. What percentage of total stock is on display during business hours? % 3. Do any employees render medical advice? 4. Do you provide written training material to your employees on how to provide cannabis product information to patrons? 5. Do you maintain the product manufacture data sheets from the manufacturers? 6. Do you have product quality control procedures? a. If yes, are these procedures in writing? 7. What percentage of your cannabis goods is pre-packaged? % 8. Do you sell any products with packaging that may be confused by young children as candy? if yes or maybe, what is the product? B. Cultivation 1. Are all electrical, plumbing and irrigation systems installed and maintained by licensed contractors? 2. How do you maintain a constant temperature in the facility? 3. How do you maintain proper ventilation in the facility? 4. Do you allow non-employees or patrons into the growing area? 5. Do you have a back-up system for the electricity supply? 6. Do you use an automatic shut off valve for watering systems? 7. Do you apply pesticides to your cannabis plants? a. If yes, state what pesticides are used? 8. Who is in charge of the health of your cannabis crop? a. Describe his or her education or training in cultivation: 9. What percentage of your cultivation operation is indoor versus outdoor? Indoor grow % Outdoor grow % C. Manufacturing 1. Are flammable solvents stored in an UL listed fire resistant cabinet? 2. Are tinctures produced using volatile solvents in the process? 3. Is hash oil being produced? a. If yes, what process is used (Butane, propane CO2, etc.)? D. Crime Information 1. How is cash held on the premises? 2. Is cash held differently at any other location to be insured under this policy? a. If yes, state how cash is held at any other location and identify that location: 3. Do you have an established schedule or protocol for cash register drops? 4. Do you contract with an armored transport service? ; a. if Yes, which service? 5. Do you require that cash be counted in the presence of two or more employees? GBC App 001 2017-12-18 6 of 7
E. Loss Experience 1. Have you or any officer or partner been declared bankrupt within the last 5 years? ; if yes, what year? ; business lost in the bankruptcy? 2. Have any protests, denials, complaints or accusations been made against your efforts to secure a license or maintain operations at the location? 3. Describe any losses claimed or sustained within the past 5 years (include loss amount): F. Prior Insurance Prior Insurance Company: Current Year 1 Year Prior 2 Years Prior General Liability Property Products Liability FRAUD WARNING 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. APPLICANT S WARRANTY STATEMENT: I have read this application and I declare that to the best of my knowledge and belief, all of the foregoing statements are true and accurate, and that these statements are offered as an inducement to issue the policy for which I am applying. I agree that all representations made in this application are material and that Golden Bear Insurance Company may rely on them. If the Company issues a policy, I UNDERSTAND AND AGREE THAT THIS APPLICATION IS INCORPORATED BY REFERENCE AND WILL BE MADE A PART OF MY POLICY. Applicant Signature Date Producer s Signature Print Name State of CA Producer License No. *** Make sure to save this document after completing by using the Save As functionality. Save a Copy with your responses and email to: Yvette Brambila : ybrambila@gomezinsurance.com or Victor Gomez: vgomez@gomezinsurance.com GBC App 001 2017-12-18 7 of 7