Nutraceutical Insurance | Vitamin Insurance Coverage

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801-451-8300
info@insur-west.com
286 S 200 W #140, Farmington, UT 84025

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Health, Nutrition & Lifestyle. Commercial General Liability Short Form Application.

Step 1 of 5

20%

Business Name*
Contact Name*
First Last
Email
Phone
Location Address*
Street Address Address Line 2 City State ZIP Code
Is Mailing Address same as above?*
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Website
Entity Type*
DBA Names

Year Business was Established*
Total Product Sales*
Foreign Product Sales*
Current Commercial General Liability Insurer*
Limits of Insurance under Current Policy*
Claims Information
Are you aware of any incident, condition, circumstance, lawsuit, legal action or suspected defect in any product or work, which may result in a demand for damages against you?*
- Yes
- No
In the most recent five (5) years, have you been subject to any liability claims, lawsuits or demands for damages, or, after inquiry, are you or any of your principals or employees aware of any circumstances or incidents which may result in such a claim?*
- Yes
- No
Product Information

Are any of your products designed or marketed for:
Use by children*
- Yes
- No
Sports nutrition – bodybuilding, muscle enhancement*
- Yes
- No
Weight-loss*
- Yes
- No
Sexual Enhancement*
- Yes
- No
Use with alcoholic beverages*
- Yes
- No
Do any of your products contain alcohol?*
- Yes
- No
If yes, is alcohol content greater than 0.5% by volume?*
- Yes
- No
Do any of your products contain any product, supplement, additive substance, ingredient or compound used in violation of any law?*
- Yes
- No
If any of your products contain caffeine, does the caffeine content exceed 300 mg per serving from all sources?*
- Yes
- No
Are any of your gross product sales generated by the following types of operations:
Importer ‐ Finished Products Sold Under Label of Others ‐ Drop Shipping to Customers*
- Yes
- No
For any product that is manufactured or formulated by you or on your behalf by others, does it contain a New Dietary Ingredient (as defined by the Federal Food, Drug and Cosmetic Act)?*
- Yes
- No

Quality Control & Regulatory Compliance
Have you voluntarily or involuntarily recalled or withdrawn, or are you considering recalling or withdrawing any products for any reason?*
- Yes
- No
Are all facilities used to manufacture, process, pack, hold or store your products registered with the FDA?*
- Yes
- No
For any product that is an ingestible, do all of your labels include a disclaimer that the FDA has not evaluated the claims on your labels and that your products are not intended to diagnose, treat, cure or prevent any disease?*
- Yes
- No
Regulatory Events
In the past five years, have you submitted a Serious Adverse Event Report (SAER) to the FDA or has the FDA notified you of a Serious Adverse Event Report submitted directly by a health care provider, firm or consumer?*
- Yes
- No
Are you aware of any complaint or notice filed in the last three years with any governmental agency or industry regulatory body, including but not limited to the FDA or FTC, concerning your product?*
- Yes
- No
Did the FDA issue a 483 Notice of Inspection?*
- Yes
- No
Are you aware of any study, analysis or trial conducted by the FDA, or any industry regulatory body, to examine the safety of your products?*
- Yes
- No
Miscellaneous Questions
Do you own any auto that is used in your business?*
- Yes
- No
Will any vehicle be operated beyond a 50 mile radius of the business location address?*
- Yes
- No
Do you have more than 5 employees?*
- Yes
- No
Will any vehicle be used for product delivery?*
- Yes
- No

Coverage Details
Policy Limit*
Deductible*
Do you have an existing and in-force Commercial General Liability Policy and require Prior Acts Coverage?*
- No Existing In‐Force Policy
- Existing / In‐Force Policy with a Retroactive Date
By selecting this option, you warrant that you have an expiring and in-force Health, Nutrition and Lifestyle Commercial General Liability policy with the same retroactive date selected below.
Expiration Date*
Retroactive Date*

I/We acknowledge that the policy being applied for will exclude all products that contain the following listed ingredients and will not defend against any claim or suit alleging injury or damage from any product that includes the following listed ingredients:
- Alcohol in the form of a beverage
- Androstenedione
- Caffeine, if more than 300 milligrams from all sources per serving
- DMAA (Dimethylamylamine, Methylhexanamine or 1,3‐dimethylamylamine)
- Ephedrine alkaloids
- Fenfluramine (N‐Nitroso‐Fenfluramine)
Or any anabolic steroids or anabolic‐androgenic steroids.

I/We declare that I/we have reviewed this Application for accuracy before signing it, that the above statements and representations are true and correct, and that no facts have been suppressed or misstated. I/We understand that this is an application for insurance only and that the completion and submission of this Application does not bind the Company to sell nor the applicant to purchase this insurance.

I/We nevertheless acknowledge that any contract of insurance issued by the Company in response to this Application will be in full reliance upon the statements and representations made in this Application. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance, or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact, commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty.

I/We hereby declare that the above statements and particulars are true and I/we agree that this Application shall be the basis for any contract of insurance issued by the Company in response to it.

I/We understand that any subsequent contract issued by the Company will be issued on a CLAIMS MADE form.
Signature of the Applicant (Principal, Partner, or Officer):*
Print Name*
Your Title*
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286 S 200 W #140, Farmington, UT 84025
801-451-8300
info@insur-west.com

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Insur-West Inc. Has been the leading Independent Insurance Agency in Utah for over 30 years. We specialize in Business Insurance, Auto Insurance, Home Insurance, Nutraceutical Insurance, Workers Compensation Insurance. We have the ability of giving you the best coverage and best price due to the high volume of Insurance Providers we are licensed to write with.

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