Insurance Tobacco Application

INSURANCE TOBACCO APPLICATION

Applicant / Insured Information

Policy Details

Requested Policy Type:

Requested Effective Date:

Policy Period From: To:

Coverage Options

Select coverages requested (checking a coverage does not bind coverage; subject to underwriting and policy terms):

Product Liability Premises Liability Product Recall Expense Product Contamination / Tampering Completed Operations Advertising Injury

Tobacco Product Information

Product Types (check all that apply):

Cigarettes Cigars Smokeless Tobacco Pipe Tobacco E-Cigarettes / Vaping Products Nicotine Pouches Hookah / Shisha Other

Manufacturer Distributor/Wholesaler Retailer Importer Exporter Online Sales

Do you have a written age verification policy? Yes No

Are all product labels and warnings applied in accordance with applicable law and regulatory requirements? Yes No

Do you maintain written testing and quality control records for products? Yes No

Claims / Loss History

Number of claims, suits or incidents in the past 5 years:

Exclusions and Declarations

The undersigned acknowledges that coverage, if issued, will be subject to policy terms, conditions, limitations and exclusions. Standard exclusions applicable to tobacco product underwriting include, without limitation:

1. Claims arising from intentional wrongdoing, criminal acts or knowing violations of law by the insured;
2. Claims arising from products sold or supplied in violation of applicable prohibitions, including sales to persons under the legal minimum age at the time of sale;
3. Punitive, exemplary or multiplied damages where not insurable as a matter of law;
4. Liability arising from misrepresentation of product contents or failure to warn where the insured knew of a defect and failed to act;
5. Bodily injury or property damage arising from pollution except where specifically endorsed.

The insurer reserves the right to apply additional specific exclusions relating to nicotine concentration, flavored products, electronic nicotine delivery systems, and jurisdictions with heightened regulatory restrictions.

Beneficiary / Payee Designation

Beneficiary or Payee for return premium or claim payments (where applicable). Percentages must total 100%.

Attachments / Documentation Checklist

Please provide the following with this application (check those included):

Product list with SKUs and nicotine content Sample product labels and warning statements Quality control / testing reports Recent sales reports Product recall and consumer notification plan Prior insurance declarations and loss runs (5 years)

Declaration and Applicant Certification

The undersigned hereby declares that the statements made in this application and any attachments are true, complete and accurate to the best of the undersigned's knowledge and belief. The undersigned further acknowledges that:

(a) All such statements are material to the insurer's determination to accept the risk and to decide the terms, conditions and rates of any policy; material misrepresentation, omission or concealment may void coverage for a claim and may entitle the insurer to rescind the policy;
(b) The insurer is authorized to obtain and verify underwriting information, loss history and other information relevant to underwriting and claims handling;
(c) Submission of this application does not bind coverage or imply that coverage will be issued; coverage will be effective only if a policy is issued, delivered, and the required premium paid;
(d) The applicant will notify the insurer in writing of any material change in the information provided prior to policy inception.

Fraud Warning: Where permitted by law, deliberate misstatements, misrepresentations, omissions or concealment of material facts may constitute fraud and could result in criminal prosecution and denial of coverage.

Applicant Attestation: I certify that the information provided is true and complete.

Signature

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