Select Solutions: Vape Application

E-Cigarette and Vaporizer General and Products Liability Application

NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO ANY CLAIM FIRST MADE AGAINST THE INSUREDS AND REPORTED IN WRITING TO THE INSURER DURING THE POLICY PERIOD OR THE OPTIONAL EXTENSION PERIOD, IF APPLICABLE. AMOUNTS INCURRED AS CLAIMS EXPENSES SHALL REDUCE AND MAY EXHAUST THE LIMIT OF LIABILITY AND ARE SUBJECT TO THE DEDUCTIBLE. PLEASE READ THIS POLICY CAREFULLY

Background Information - Please Read:

1. Please type or print clearly.
2. Answer ALL questions completely leaving no blanks. If any questions, or part thereof, do not apply, print N/A in the space.
3. If additional space is needed to answer any questions fully, please attach a separate page.
4. This application must be completed, dated and signed by a Principal of the Applicant.

I. Applicant Information

Name of Applicant(s) (and list all subsidiary companies):

Mailing Address:

City:

State:

Zip:

Location(s):

Telephone:

Website:

Email:

Contact Name:

Applicant is:

Other:

Date of Incorporation/Start of Operations:

Gross Sales

Projected Next 12 Months:

Battery exposures:

(Single Cell Batteries, Unsealed Mods and Chargers)

E-Liquids & Accessories:

(E-liquids, Tanks,Coils, Wicks, Mouth Pieces, Drip Tips, Sealed Mods, Vape & Shisha Pens)

Total Sales:

This Year (Year to Date):

Battery Exposures:

(Single Cell Batteries, Unsealed Mods and Chargers)

E-Liquids & Accessories:

(E-liquids, Tanks,Coils, Wicks, Mouth Pieces, Drip Tips, Sealed Mods, Vape & Shisha Pens)

Total Sales:

Last Year:

Battery Exposures:

(Single Cell Batteries, Unsealed Mods and Chargers)

E-Liquids & Accessories:

(E-liquids, Tanks,Coils, Wicks, Mouth Pieces, Drip Tips, Sealed Mods, Vape & Shisha Pens)

Total Sales:

Any Foreign Sales?

Yes

Please list all countries and % sales:

Is the applicant owned by, affiliated with or working for a tobacco company?

Yes

II. Hardware/Components

What products do you manufacture (M), sell (S) or distribute(D):

1.) E-Cigarettes/Vaporisers (cigalikes, e hookah pens, aromatherapy inhalers, dry herb vaporiser):

2.) Mod with sealed batteries:

3.) Batteries and chargers (single cell batteries - not including sealed batteries within mods):

4.) Accessories (tanks, coils, wicks, drip tips, mouthpieces):

5.) Heat not burn devices (devices designed to consume tobacco):

Do you have other hardware/components products?

Yes

Describe product:

Also indicate whether you manufacture, sell or distribute this product.

If you are selling or distributing only - who are the manufacturers you work with and where are they located? (all must be listed):

Are you included as an AI on the insurance of your suppliers?

Yes

Are you selling batteries?

Yes

Do all of the batteries and chargers you distribute/sell come with CE certification or similar?

Yes

Do all of the batteries and chargers you sell have a safety mechanism to prevent overcharging?

Yes

Do you sell any of the following brands: 1. E-Fest || 2. MXIO || 3. LG || 4. Imren?

Yes

Please enter sales for each brand:

Do you rewrap or sell rewrapped batteries?

Yes

Do you sell charging bags or carry cases?

Yes

Where do you source your batteries from?

III. E-Liquids

What products do you Manufacture (M), Sell (S) or distribute (D):

1.) Finished E-Liquids (NOTE – mixing of PG/VG, Nicotine and flavourings is considered manufacture of finished e liquids

2.) Flavorings or Flavoring Extracts:

3.) Propylene Glycol or Vegetable Glycerine:

4.) Liquid Nicotine:

Do you have any other E-Liquid products?

Yes

Describe product:

Also indicate whether you manufacture, sell or distribute this product.

Do your liquids contain:

1.) Tobacco Extracts?

Yes

2.) High Strength Nicotine Salts?

Yes

If liquids contain High Strength Nicotine Salts, are they labelled not for use with high power sub ohm devices?

Yes

Are you a member of AEMSA?

Yes

Are your products manufactured by you?

Yes

If the products you sell are not manufactured by you – please confirm the name of supplier or contract manufacturer and country of origin:

Where do you source your flavoring chemicals, PG/VG and Liquid Nicotine? (List Country of origin and Supplier )?

Are these ingredients USP (US Pharmacopoeia) grade certified or equivalent?

Yes

Do you purchase these ingredients in bulk?

Yes

Do you store appropriately and manage expiry dates?

Yes

Do you receive product safety data sheets with your flavors?

Yes

Are the flavoring extracts you purchase from a 3rd party supplier made specifically for use within e liquids?

Yes

Where are E-Liquids mixed:

Dedicated Clean Room?

Yes

Contracted out to a 3rd party lab:

Yes

Warehouse:

Yes

Staff only area in store:

Yes

Counter in store or Vape Lounge as required:

Yes

Other (please describe):

Warranties:

The applicant understands that no coverage shall be afforded to finished products manufactured subsequent to the effective date of any policy issued which is based on this application:

1) which the nicotine content has not been tested (by titration or other relevant method) to verify the final content matches the amount declared on the label.
2) which are not sold in child proof/ tamper proof containers.
3) which do not have warnings (see section V) on the label.
4) Nicotine products sold in California without a Prop 65 warning on the label.

The applicant further understands that, as a requirement of coverage, all manufacturers must sterilise their mixing/testing/extraction equipment using FDA approved chemicals or alcohols or via Autoclave system.

Please check to confirm you accept the warranties:

Does your E-liquid contain Taurine, Caffeine or any Stimulants OTHER than Nicotine?

Yes

Please list

Does your e-liquid contain CBD, THC, or other cannabinoids?

Yes

Please list:

What percentage of sales is for Marijuana related products?

IV. Vape Shops

Are E-liquid flavour combinations mixed by employees only?

Yes

Do you offer free flavor samples?

Yes

Are your samples Nicotine free?

Yes

Are the staff appropriately trained on how to handle liquid nicotine and aware of the dangers associated with spillage ?

Yes

Does this location have a hookah lounge or vaping lounge?

Yes

Does this location have any of the following:

1.) Live Music/DJs:

Yes

2.) Bouncers/Doormen:

Yes

3.) Liquor Sold/Served:

Yes

4.) Fresh Food Service:

Yes

Would you like your GL coverage to extend to events in your vaping lounge?

Yes

V. Warnings

Do you warn your customers about:

1.) Nicotine and addiction?

Yes

2.) Explosion risk due to overcharging and charging with incompatible devices (including USB, car adaptors and iPhone chargers)?

Yes

3.) Toxicity of E-Liquid if spilled on skin?

Yes

4.) Dangers of inappropriate storage of batteries (i.e. loose in pocket/handbags)?

Yes

Do you advise how e liquid should be stored and disposed of?

Yes

Do you promote your products as a smoking cessation device?

Yes

Do you promote your products as Healthy or a healthy living choice?

Yes

VI. General Information

Have any of your products been discontinued or recalled in the past 5 years, for reasons other than popularity?

Yes

Please explain:

Are you planning to introduce any new products (other than new flavours) in the next 12 months?

Yes

Please list product(s):

Can your products be identified from those of competitors?

Yes

Do you keep comprehensive sales records for your customers and if so for how long ? ( i.e. if asked – could you verify what was sold to a specific customer on a specific date)

Yes

Insured History - Claims, Losses, Incidents

Have you had any claims in the past 5 years?

Yes

Please Explain:

Please attach loss runs:

Are you aware of any incident(s) that may result in a claim not reflected in the above question?

Yes

Please explain:

VII. Coverage History

Carrier:

Limits:

Premium:

Rate:

Term:

Deductible/SIR:

Coverage Form:

Retro Date:

Has the applicant ever been declined or refused coverage, or had its coverage cancelled or non-renewed?

Yes

Please explain:

VIII. Coverage Request

Limits of coverage/deductibles:

Coverage:

Limits requested:

Deductible requested:

Retroactive date requested:

Coverage:

Limits requested:

Deductible requested:

Retroactive date requested:

Do you require a Blanket Vendors Additional Insured Endorsement?

Yes

Do you require an individual Vendors Additional Insured Endorsement?

Yes

Please provide name, address, and any special wording requested by the vendor/distributor:

Do you require an individual a Landlord/Lessor Additional Insured Endorsement?

Yes

Please provide name, address, and any special wording requested by the landlord/lessor:

Other:

I understand and agree this Application and any supplements attached hereto will be relied upon for issuance of any policy. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the company, result in the voiding of the insurance issued in reliance on this application and/or denial of claims under any policy issued.

I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to engage in the activities of my business including authorization to every person or entity, public or private, to release to all Lloyd’s of London participating syndicates, any documents, records or other information bearing upon the foregoing. I understand and agree these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law.

Furthermore, I understand that the policy applied for will apply only to CLAIMS FIRST MADE AND REPORTED to the Company in writing within the period of coverage shown on the certificate of insurance issued with the policy or certificate on the date the policy is canceled or terminated, whichever comes first or as otherwise provided by the policy.

I understand this insurance is being provided through a surplus lines company and the insurer may not be subject to all the insurance laws and rules in my state and the risk is not protected by the State Insurance Insolvency Fund

Warning

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT (S)HE IS FACILITATING A FRAUD AGAINST THE INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD, AND SUBJECT TO STATE FINES.

THIS APPLICATION MUST BE SIGNED BY APPLICANT WITHIN 30 DAYS OF BINDING. SIGNING THIS FORM DOES NOT BIND THE COMPANY TO COMPLETE THE INSURANCE. COVERAGE BECOMES EFFECTIVE WHEN ACCEPTED BY THE INSURANCE COMPANY.

Applicant Signature:

Title:

Date:

Requested Effective Date:

Please select the Select Solutions broker you are currently working with (If Known):

Broker: