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
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
Projected Next 12 Months:
This Year (Year to Date):
What products do you manufacture (M), sell (S) or distribute(D):
What products do you Manufacture (M), Sell (S) or distribute (D):
Do your liquids contain:
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
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.
IV. Vape Shops
Does this location have any of the following:
Do you warn your customers about:
VI. General Information
Insured History - Claims, Losses, Incidents
VII. Coverage History
VIII. Coverage Request
Limits of coverage/deductibles:
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
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.