Cannabis Insurance Application — Licensed Growers

1General Information
2Location Information
3Property Coverage
4Indoor Crop
5Inland Marine
6Cultivation Operations
7Delivery & Distribution
8Manufacturing/Extraction
9Non-Owned/Hired Auto
10Products Liability
11History & Signature

General Information

Agent Details

Agent First Name *

Agent Last Name *

Agent Email *

Agent Phone *

Producer / Agency Name *

Agency Code *

Business Information

Applicant Name *

Legal Business Name *

DBA (if applicable)

Mailing Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

Entity Type *

Corporation Partnership LLC Individual

Effective Date *

Operations * (Select all that apply)

Cultivation Processing/Packaging (Non-Extraction) Delivery to End User (For Consumption) Lab Testing Manufacturing of Items (Non-Extraction) Distribution to Other Businesses Extraction Adult Use Retail Store Sales Medicinal Use Retail Store Sales Distilling/Refining White Labeling of Products for Others CBD/Hemp Retail Store Sales Wholesale/Distribution (No Transportation) Other:

THC content ≤0.03% only? *

Yes No

New Venture (business operating less than 12 months)

Total Gross Sales — Last 12 Months

Total Gross Sales — Next 12 Months (Projected)

Online Sales Percentage (%)

License Type(s)

License Number

Type of License 2 (optional)

License Number 2

Type of License 3 (optional)

License Number 3

If Not Licensed — Please Explain

Trade Association Membership

CCSE NORML NCIA CCIA Other:

If Selling to the Public

Onsite consumption allowed?

Yes No

Verify age at time of sale?

Yes No

Medicinal: Keep physician records?

Yes No

Controlled access at location?

Yes No

Written/electronic inventory records?

Yes No

3rd party security guard firm?

Yes No

Guards carry own insurance + AI?

Yes No

If armed: comply with laws?

Yes No

Coverage Requested

General Liability?

Yes No

Products Liability?

Yes No

Property Coverage?

Yes No

Location Information

Location 1

Location / BLDG #

Number of Buildings / Structures

Physical Address *

City *

State *

Zip Code *

Fully Open & Operational? *

Yes No

Hours of Operation

Expected Open Date

Operations at this location

Square Footage

Year Built

Plumbing Updated Year

Electrical Updated Year

HVAC Updated Year

Sprinklers?

Yes No

% of building covered

Construction Type

Year Roof Last Updated

No. of Stories

Year Roof Last Fully Replaced

Roofing Material

Power Sources (Select all that apply)

Generator Solar Panels

Currently Under Renovations?

Yes No

Describe renovations & estimated completion

Residential Exposure?

Yes No

Owner Occupied?

Yes No

Security Questions

Central Station Burglar Alarm?

Yes No

Motion Detectors?

Yes No

Please explain (no motion detectors)

Safe at location?

Yes No

Bolted to ground?

Yes No

Cannabis Finished Stock Storage (Select all that apply)

Vault Room Metal Shipping Container Security Cage Safe Other

Finished CBD Stock Storage (Select all that apply)

Vault Room Metal Shipping Container Security Cage Safe Other

Harvested Cannabis Material Storage (Select all that apply)

Vault Room Metal Shipping Container Security Cage Safe Other

Cannabis Finished Stock — Other (describe)

Finished CBD Stock — Other (describe)

Harvested Cannabis Material — Other (describe)

Vault / cage / container in compliance?

Yes No

Security Cameras?

Yes No

Interior cameras?

Yes No

Exterior cameras?

Yes No

Additional Insured

AI Type (Select all that apply)

Landlord Lessor of Leased Equipment Governmental Agency Waiver of Subrogation Primary/Non-Contributory Other:

AI Name and Mailing Address

Property Coverage

Skip — Declining Property Coverage

Location 1

Location / BLDG # (reference Step 2)

Building Coverage

Building Applicability (Select all that apply)

Owner of Building Modular/Pre-fab Triple Net Lease

Equipment

Tenant Improvements

Business Personal Property

Outdoor Signs

Loss of Business Income — Per Month

Months Covered

Cannabis Finished Stock

% of Total Stock

% Refrigerated

Refrigeration Tier

None refrigerated Some (1-50%) All / Most (51-100%)

Finished CBD/Hemp Stock

Loss Payee?

Yes No

Loss Payee Type

Mortgagee Loan-Leased

Loss Payee Name and Address

Optional Coverages

Property Extension Limit

$10,000 $25,000 No

Ordinance or Law?

Yes No

Coverage A Limit

Coverage B Limit

Coverage C Limit

Equipment Breakdown?

Yes No

ACV Acknowledgment

I understand that the Finished CBD and Cannabis Stock limits above are insured on an Actual Cash Value (ACV) basis.

Signature *

Date

Indoor Crop

Skip — Declining Indoor Crop Coverage

Location / BLDG #

Living Plant Material Limit

Harvested Cannabis Material Limit

Inland Marine

Skip — Declining Inland Marine Coverage

Location / BLDG # (reference Step 2)

Contractors Equipment

Item 1

Description & Serial #

Total Value

Mobile Scheduled Property

Item 1

Description

Total Value

Property in Transit

Property in Transit Including Stock

Cash in Transit

Bailees Coverage

Property in Transit Including Stock

Cash in Transit

Property at Insured's Premises

Cultivation Operations

Skip — No Cultivation Operations

Location / BLDG #

Physical Address

Grow Operations Type (Select all that apply)

Indoor Outdoor Greenhouse

Indoor Grow

Security Features (Select all that apply)

Motion Detectors 24hr Live Monitored CCTV Other:

Lighting Type *

100% LED 100% HPS 100% MH 100% HPS/MH LED/HID Mix Other:

Ballast Model

Ballast Type

Magnetic Digital/Electronic Other

Ballast Type — Other (describe)

Digital ballast designed for which bulb? (Select all that apply)

MH HPS MH & HPS Other

Digital Ballast Bulb Type — Other (describe)

Ballasts modified beyond manufacturer specs?

Yes No

Bulb Manufacturer(s)

Bulb Model(s) and Type(s)

SE or DE Bulbs?

SE DE

Different bulbs in veg vs flower?

Yes No

MH and HPS interchangeable?

Yes No

MH bulbs used in HPS ballasts?

Yes No

Follow manufacturer instructions?

Yes No

If No, explain

Bulb Replacement Frequency

At 70% of life At 80% of life When they burn out

Bulb Replacement Frequency — Other (describe)

Monitored quality check?

Yes No

Water/combustibles within 5ft of lighting?

Yes No

Outdoor Grow

Fencing around grow area?

Yes No

Barbwire/razor/electric fencing?

Yes No

Warning signs posted?

Yes No

Gates at all entrances, locked?

Yes No

Total Property Size (acres)

Grow Operations Size (acres)

Greenhouse

Fully enclosed with locking doors?

Yes No

Has power?

Yes No

Has grow lighting?

Yes No

Construction (Select all that apply)

Glass Roof Metal/Wood Siding Metal Roof Plastic Sheeting Windows that Open Hoop House Solid Plastic/Polycarbonate Siding Solid Plastic/Polycarbonate Roof Retractable Roof/Sides Other

Fire Safety & Pesticides

Fire extinguishers present at the location?

Yes No

Smoke detectors installed?

Yes No

Posted evacuation plan?

Yes No

Pesticide use / storage compliant with local regulations?

Yes No

Electrical Warranty

Electrical Warranty Statement *

All electrical work has been completed and was performed by a licensed and insured contractor. All permits were pulled, inspections completed, and the electrical meets or exceeds local codes. We are not ready to start electrical work yet. We agree that before any electrical work is started, all work will be completed by a licensed and insured contractor with all required permits and inspections. No electrical changes were made by us, but we have, or will have, within 30 days, a licensed and insured electrician inspect all existing wiring and certify it meets or exceeds local code requirements. There is no electricity for the cultivation operations at this location.

Signature *

Date

Delivery & Distribution

Skip — Declining Delivery/Distribution Coverage

Transport in unassuming vehicle?

Yes No

Policy to collect ID/uniforms from departing employees?

Yes No

GPS tracking in all vehicles?

Yes No

Transportation across state lines?

Yes No

If yes — please explain

Two employees in vehicle during transport?

Yes No

One employee remains in vehicle at all times?

Yes No

Current Commercial Business Auto Policy?

Yes No

Carrier Name

Policy Limits

If no — please explain

Distribution: advise customers of delivery staff changes?

Yes No

Delivery Frequency (Select all that apply)

Daily Weekly Monthly Other

Frequency — Other (describe)

Hired Auto coverage requested?

Yes No

Driver Screening / Background Check Program in place?

Yes No

Manufacturing/Extraction

Skip — Declining Manufacturing/Extraction Coverage

Products manufactured (Select all that apply)

Budder/Shatter Tinctures Concentrates/Oils E-Liquids/Vape Cartridges Edibles: Other:

Use non-cannabis materials in manufacturing? *

Yes No

New products proposed in next 12 months?

Yes No

List new products

Products tested and labeled to standards?

Yes No

Emergency Evacuation Procedure in place?

Yes No

Child-Resistant Packaging used?

Yes No

Product labels comply with state & federal regulations?

Yes No

Product Recall Plan in place?

Yes No

Edible Operations

Cooking types used (Select all that apply)

Grilling Barbecuing Open-Broiling Solid Fuel Deep-fat Frying Roasting

Ansul system installed?

Yes No

Food Safety Certifications current?

Yes No

Catering operations?

Yes No

Kitchen rented to others?

Yes No

If bakery — public seating available?

Yes No

Extraction Operations

Extraction method (Select all that apply)

Alcohol/Ethanol CO2 Butane Ice Water/Rosen Press Propane Other:

Closed loop system used?

Yes No

Employees trained on extraction?

Yes No

SOPs in place?

Yes No

Routine maintenance performed?

Yes No

Extraction in dedicated room?

Yes No

Equipment per manufacturer specs?

Yes No

Modifications beyond manufacturer intent?

Yes No

Ventilation system installed?

Yes No

Gas detection system?

Yes No N/A

Hydrocarbon Extraction

Lab/extraction area sprinklered?

Yes No

Near spark sources?

Yes No

Flammable liquids stored in UL-approved container?

Yes No

CO2 Extraction

Cylinders secured?

Yes No

Pressure relief piped to exterior?

Yes No

Adequate clear space around cylinders?

Yes No

Non-Owned/Hired Auto

Skip — Declining Non-Owned/Hired Auto Coverage

Non-Owned Auto coverage requested?

Yes No

Hired Auto coverage requested?

Yes No

Current Commercial Business Auto Policy?

Yes No

Why is this coverage requested?

Do any vehicles require a CDL?

Yes No

Number of employees

Independent contractors

How many use personal vehicles for business?

How often are personal vehicles used?

Daily Weekly Monthly Other:

Circumstances of use

Non-Owned auto trips annually

Under 10 10–50 50+

Hired Auto trips annually

1–5 6–10 11+

Require employees to carry their own auto insurance?

Yes No

Minimum limits required

Require proof of insurance before authorizing use?

Yes No

Copy obtained on renewal?

Yes No

Typical radius from business

Anyone with DUI/DWI/Reckless driving history?

Yes No

MVR (Motor Vehicle Record) review cadence

Driver Training Program in place?

Yes No

Limits requested

$250,000 $500,000 $1,000,000

Signature *

Title

Date

Claims Made Products Liability

Skip — Declining Claims Made Products Liability Coverage

Products covered (Select all that apply)

Concentrates/Oils Tinctures Cannabis Vape Pens and Accessories Edibles Cannabis Vape Cartridges Herbs/Flowers Other:

Highest concentration (%)

Highest dosage (mg)

If >70% concentration or >50mg dosage — distributed only to qualified patients?

Yes No

If no — how do you control access?

Third party lab testing performed?

Yes No

If no — how do you ensure purity?

Products released to market before testing complete?

Yes No

Include Retro Coverage?

Yes No

Retro Date

Include Product Withdrawal coverage?

Yes No

Full Product List (one per line)

Signature *

Date

History & Signature

Claims History

Has this application ever been declined, cancelled, or non-renewed?

Yes No

Please explain

Currently have insurance coverage?

Yes No

Insurer

Type of Policy

Coverage Limits

Premium

Expiry Date

Prior liability or property claims in the past 5 years?

Yes No

Please provide details

Felony or DUI conviction in the last 10 years (owners, officers, or employees)?

Yes No

Names of those convicted

Compliant with all local and state cannabis laws and regulations?

Yes No

Bankruptcy filed in the last 5 years?

Yes No

Type of Bankruptcy

Chapter 7 Chapter 11 Chapter 13

Contact Information

Inspection Contact

Name

Phone

Retail Insurance Agent

Name

Phone

Audit Contact

Name

Phone

Compliance Certification

I hereby certify and confirm that we are not involved in any of the following:

Revenue from the sale of cannabis going to criminal enterprises, gangs, and cartels

Diversion of cannabis from legal states to illegal states

Cannabis activity as a cover for trafficking other drugs

Promotion of drugged driving or adverse public health consequences

Cultivation on public lands or federal property

I certify the above statements are true *

Producer Signature

To be completed by the submitting producer/agent.

Producer Signature (type full name) *

Producer Title *

Agency / Producer Code *

Date

Requested Effective Date *

Terrorism Coverage Disclosure

Disclosure of Terrorism Coverage

You are hereby notified that under the Terrorism Risk Insurance Act, as amended, you have a right to purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1) of the Act: The term "act of terrorism" means any act or acts that are certified by the Secretary of the Treasury — in consultation with the Secretary of Homeland Security and the Attorney General of the United States — to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.

YOUR POLICY DOES NOT CURRENTLY INCLUDE COVERAGE FOR LOSSES CAUSED BY ACTS OF TERRORISM. Coverage for such losses may be available for an additional premium. Please discuss this with your insurance agent or broker.

Do you elect to purchase terrorism coverage?

Yes No

Premium Amount

Insurer

Policy Number

Signature

Print Name

Date

✅ Application received — thank you! Billy at BNW Services will review it and reach out.

— then it's ready to email to Carma. Anything urgent? Call 573-594-5148.

InsureToday24 — BNW Services LLC · Licensed MO · KS · NE · TN · OK · AR · CO · For licensed, state-legal cannabis operations only · Cannabis cultivation insurance · Disclosures