THC Impairment Liability Insurance Quote Request

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We will process your request upon receipt.

Step 1 of 4

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Name(Required)

First Last

Your entity is(Required)

Full Legal Business Name(Required)

Does your company use any DBA or Trade Names(Required)

Yes

What DBA or Trade Name(s) do you use or have used?(Required)

Email(Required)

Phone Number(Required)

Alt Phone Number (cell, home)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Website

Date Business Started(Required)

MM slash DD slash YYYY

General Location Information

Is your business address different from the mailing address you indicated?(Required)

Yes

Physical Address of Business(Required)

Street Address Address Line 2 City State ZIP Code

If the location address differs from your mailing address, enter the location address below.

Provide a brief description of the operation(Required)

What kind of food, take out or dine in, fast food, fine dining...

Sales

THC Product Revenue - Annual(Required)

Upcoming Year

Last 12 months

1 Yrs Prior

2 Yrs Prior

3 Yrs Prior

If $0 enter "ZERO"

Liquor - Annual(Required)

Upcoming Year

Last 12 months

1 Yrs Prior

2 Yrs Prior

3 Yrs Prior

If $0 enter "ZERO"

Other Revenue - Annual

Upcoming Year

Last 12 months

1 Yrs Prior

2 Yrs Prior

3 Yrs Prior

If $0 enter "ZERO"

Food Revenue - Annual

Upcoming Year

Last 12 months

1 Yrs Prior

2 Yrs Prior

3 Yrs Prior

If $0 enter "ZERO"

Approximately what percentage of the total annual impairment product sales revenue is attributed to e-commerce(Required)

OPERATIONS

What are your operations? Check all that apply.(Required)

Restaurant

Bar or Tavern

Private Banquet Hall

Sport Stadium

Gas Station/Convenience Store

Grocery Store

Brewery

Winery

Distillery

Event Venue/Concert Hall

Nightclub

Gentleman's Club

Casino

Catering

Event Server Staffing

Budtender Services

Mobile Services

Delivery

Other

If Other from above, please explain(Required)

How many years have you been in operation under this business name, or any other business names?(Required)

Please enter a number from 0 to 100.

Please describe your impairing products(Required)

Cannabis - medical

Cannabis - recreational

Ketamine

Ayahuasca

Psilocybin mushrooms

Kratom

Other

If other, please explain what substances.(Required)

Do you mix or combine any of the above described impairing products with other products?(Required)

Yes

If yes, please describe.(Required)

Do you have regular operating hours where any impairing product is served?(Required)

Yes

Operating Hours

What are your operating hours for each day. If closed on a particular day, indicate "CLOSED"

List

Mon

Tue

Wed

Thu

Fri

Sat

Sun

If no regular operating hours, answer the following

How many days/nights, on average, are you open a month (with impairing product sales)?(Required)

Please enter a number from 0 to 31.

Do you have seasonal operation?(Required)

Yes

If you have seasonal operation, please describe:(Required)

Events

Do you host or attend any off-premises events, conventions, or trade shows?(Required)

Yes

Approximately how many events will you attend during the next year?(Required)

Please enter a number from 0 to 500.

Please describe the nature of the event(s):(Required)

Approximately how many attendees are expected on average for the events:(Required)

Please enter a number from 0 to 50000.

What percentage of attendees are expected to consume your impairing product?(Required)

Please enter a number from 0 to 100.

Do you currently have a valid liquor, cannabis, or other impairing product license?(Required)

Yes

If yes, please describe what type(s):(Required)

What date was this license issued?(Required)

MM slash DD slash YYYY

If no, please advise when you expect to be permitted/licensed:(Required)

MM slash DD slash YYYY

Are you a member of any trade association associated with your impairing products?(Required)

Yes

What trade association are you a member of?(Required)

How many servers that handle impairing products do you have?(Required)

Please enter a number from 0 to 500.

Are ALL of these servers certified?(Required)

Yes

What certification(s) do they receive?(Required)

If no, what percentage are certified?(Required)

Please enter a number from 0 to 100.

If you are not utilizing a certification, please describe the server training process all servers must complete before handling impairing products:(Required)

Are there any employed professionals on staff (e.g. physicians or pharmacists)?(Required)

Yes

If yes, do the employed professionals carry their own separate professional liability insurance?(Required)

Yes

Are servers (or any other employees) permitted to use impairing products during their hours of employment or service?(Required)

Yes

Do you ever utilize volunteer labor for serving of impairing products?(Required)

Yes

Is your establishment 21+ only?(Required)

Yes

Do you have dedicated door or host staff that checks the ID of all patrons at the time of entry?(Required)

Yes

Do you have an ID scanning and image retention system?(Required)

Yes

Do you offer any of the following impairing product specials? Check all that apply:(Required)

Happy Hour/Angry Hour

2 for 1 Specials

Special Promotion Night

Bring Your Own

Complimentary Products

All You Can Eat/Drink/Use

To-Go/Takeout/Take Home

Other

NONE OF THE ABOVE

Provide & Explain the "other" in detail(Required)

Do you offer or host any entertainment in your establishment? Check all that apply:(Required)

Dance Floor

DJs

Live Bands

Karaoke Booths

Open Mic Karaoke

Standup Comedy

Open Mic Performance

Mechanical Rides/Bulls

Video Games/Amusement Devices

Bingo or Trivia

Athletic Events

Tabletop, Board or Card Games

NONE OF THE ABOVE

Other

Provide & Explain the "other" in detail(Required)

How frequently is this entertainment offered?(Required)

Do you have written policies and procedures requiring employees to refuse service to minors and persons visibly under the influence?(Required)

Yes

Do you have any security or bouncers?(Required)

Yes

If yes, are these personnel employed by you?(Required)

Yes

If no, is the third party service required to hold you harmless for their operations and provide a COI showing proof of liability insurance?(Required)

Yes

Do you utilize any off-duty police officers for security?(Required)

Yes

If yes, do officers carry their service firearms while on your premise?(Required)

Yes

Do you contract K9 unit officers who bring their dog to your premise?(Required)

Yes

Are security guards/bouncers armed?(Required)

Yes

If yes, do they carry firearms?(Required)

Yes

If yes, do they carry Tasers/stun guns??(Required)

Yes

If yes, do they carry Mace/pepper spray?(Required)

Yes

Do you offer valet parking?(Required)

Yes

If yes, is this service provided by your employees?(Required)

Yes

If yes, do you currently have liability coverage for the valet operations?(Required)

Yes

If no, is the third party service required to hold you harmless for their operations and provide a COI showing proof of liability insurance?(Required)

Yes

Have you ever been assessed a fine for violation of a law concerning the sale of an impairing product or had your impairing product license suspended?(Required)

Yes

Please provide a detailed explanation as to the fine or violation, the date it occurred, penalty paid, and length of the suspension.

Have you had any Impairment Liability claims that were or were not covered by insurance?(Required)

Yes

Please provide a detailed explanation as to the date of the claim, the nature of the claim (what caused it) and the amount paid.

During the past five years, has any insurer ever canceled or non-renewed similar insurance to any applicant or has your insurance been canceled for nonpayment of premium by any insurance or finance company?(Required)

Yes

Please provide a detailed explanation as to the reason for the cancellation or non-renewal.

Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages or accidents arising out of or related to your operations that a reasonably prudent person might expect to give rise to a claim or lawsuit, whether valid or not, which might directly or indirectly involve the company?(Required)

Yes

Please provide a detailed explanation as to what current circumstances may give rise to a claim.

What Impairment Liability Limit are you seeking(Required)

Has our company ever filed Bankruptcy or Reorganization(Required)

Yes

Final Details

How soon do you need this quote(Required)

Date quote needed by(Required)

MM slash DD slash YYYY

What date do you need this coverage by?(Required)

MM slash DD slash YYYY

How did you hear about us?

If you were referred, who can we thank with a nice gift?

What other coverages are you interested in?(Required)

None

Cyber Liability

Directors & Officers

Disability

Group Health

Employment Practices Liability

Workers Comp

Requested Cyber Liabilty Limit(Required)

Please estimate total number of customer and employee records you store either electronically or in physical files?(Required)

How many female employees do you have(Required)

How many male employees do you have(Required)

What is your total annual gross payroll?(Required)

What is the company's Federal Tax ID #

We need this to provide a Workers Comp quote

Other things I want to tell you that you didn't ask. Additional comments, concerns, circumstances, or coverages you have/want.

Attachments

Drop files here or

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Please feel free to attach any files that might be useful in rating your coverages... Prior or current policies, loss runs, claims, photos of delicious food, the interior of your hookah bar or hash den, pictures your kids drew in kindergarten...