Total gross receipts from all products and services listed above:
Provide the following for present Product Liability insurance.
It is agreed there is no coverage afforded under this certificate for the following product(s): Derivatives, related botanicals, and/or extracts whether as a primary ingredient or in combination with other ingredients.
Any product, supplement, or additive determined by the United States Food and Drug Administration at any time to be a Class I Health Hazard. Class I Health Hazard means a product presenting a reasonable probability that the use of or exposure to it will cause serious adverse health consequences or death.
PLEASE ENTER YOUR INITIALS BELOW CONFIRMING THAT YOU HAVE READ AND UNDERSTAND THE PRODUCTS LISTED ABOVE ARE EXCLUDED
NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY
No fact, circumstance, or situation indicating the probability of a claim or action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, circumstance, or situation, any claim subsequently emanating there from shall be excluded from coverage under the proposed insurance. For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s)proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this application and in any attachments, are true and complete. Beazley Group plc. or the Company is authorized to make any inquiry in connection with this application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance. This application, information submitted with this application and all previous applications, and material changes thereto of which Beazley Group plc. receives notice, is on file with Beazley Group plc. and is considered physically
attached to and part of the policy if issued. Beazley Group plc. and the Company will have relied upon this application and all such attachments in issuing the policy. If the information in this application and any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify Beazley Group plc, who may modify or withdraw any outstanding quotation or agreement to bind coverage. The undersigned declares that the person(s) and organization(s) proposed for this insurance understands that:
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 Beazley Group plc. Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, 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).