Instructions: Answer all questions. If the answer is NONE, please state “NONE.” Attach copies of all labels including the ingredients with the application. Application must be signed and dated by an officer of the company
Please confirm the following are true:
1. You maintain record of design changes and reasons justifying these changes.
2. Your designs are subject to independent external review, testing or certification.
3. Warranties are obtained from all suppliers.
4. Quality control records are kept so that you can identify at a later date what tests you applied to a given product at a given time.
5. Warning labels comply with federal statutory warning labeling requirements.
6. All product labeling complies with FDA guidelines.
7. You expressly disclaim or limit warranties for your products.
8. You provide specific training/instructions for the user in the proper use of your product.
9. You have a procedure to record data on product related complaints, accidents, or injuries.
10. Your procedure provides for examining and preserving any allegedly defective product, with the results of such examination recorded.
11. You maintain copies of old instruction or operation manuals and advertising material.
12. Your products have not been investigated for safety by any government agency.
You understand the following are excluded from the policy and there will be no coverage for claims arising out of these products:
Consumable alcoholic products, any product containing cannabidiol (CBD), any product developed with or containing human stem cells or human stem cell media, drugs, medicines, or products requiring a prescription, Formaldehyde or products containing Formaldehyde, furniture, hand sanitizer not in compliance with "The United States Food & Drug Administration's Temporary Policy for Preparation of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency (COVID-19) Guidance for Industry",invasive body inks or permanent cosmetics, invasive products intended to remain within the body, inversion tables, nail curing lights, Nutraceuticals, Pharmaceuticals, plugin electrical products, suppositories, tanning beds or equipment, toys (except when sold in conjunction with an eligible beauty product),
Cyber Coverage Options (Data Breach/Privacy Insurance)
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 and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
Applicable in Colorado: 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.
Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).
Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in Maine, Tennessee, Virginia and Washington: 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 a denial of insurance benefits.
Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.