Canopius US Insurance Cannabis and Hemp Operations Cultivation Lighting Supplemental Application NameFirstLast Business Name: Grow AddressFor purposes of this application, the following acronyms are used:HID = High Intensity DischargeLED = Light-Emitting DiodeMH = Metal Halide/Ceramic Metal Halide HPS= High Pressure Sodium Type of lighting used at the cultivation facility:100% LED (Light Emitting Diode) NO FURTHER RESPONSES REQUIRED IF CHECKED100% HID (High Intensity Discharge)LED/HID MixOther Name of ballast manufacturer(s): Ballast model name(s)/numbers(s): Type of ballast(s) used in your operation:MagneticDigital/ElectronicOther If you are using a Digital/Electronic ballast, what type of bulb is it designed for?MHHPSMH & HPSOther If other, please describe the type of bulb: Have you modified the ballasts beyond manufacturer specifications?NoYes If you have modified the ballasts, please explain any modifications below: Name of light bulb manufacturer(s): Bulb model(s) and type(s) used in your operation (model name/number, and type such as MH, HPS, LED, etc.): Do you use single-ended (SE), or double-ended (DE) bulbs?DESEBOTH Do you use different types of bulbs in the vegetative phase versus the flower phase?NoYes Do you ever use Metal Halide and High Pressure Sodium bulbs interchangeably in your fixtures?NoYes If yes to question above, do you ever use Metal Halide bulbs in High Pressure Sodium ballasts? (Note: Yes answer could lead to automatic decline)NoYes If lamps are in continuous operation, are they turned off for at least 15 minutes once a week? NoYes Are the lights inspected to prevent bulb explosion? NoYes Is bulb hour usage tracked and maintained?NoYes Bulb Replacement schedule - following manufacturer guidelines or better? NoYes Theft coverage is excluded if your burglar alarm is Ring, Blink, Simplisafe, Nest etc. Do you use any of these alarm systems at this location? (Central Station Burglar Alarm that reports to 3rd party/police is required)NoYes Approximately how many employees do you have at this location? This Application is the basis for coverage; therefore, any incorrect or incomplete statements or answers could nullify coverage. Completion of this form neither binds coverage nor guarantees that a policy will be issued. (Not applicable in North Carolina) The Insurer will rely upon this application and all such attachments in issuing the policy. If the information in this application or any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify the Insurer, who may modify or withdraw any outstanding quotation or agreement to bind coverage. I hereby request that my application for insurance coverage be submitted for consideration to the company shown in this application. Accordingly, I authorize and direct any person or organization whatsoever to release and furnish to that company any and all information requested which may relate to my insurability. I hereby indicate that the aforementioned statements and answers are correct and complete. I further understand that an incorrect or incomplete statement or answer could void my protection. I hereby consent to the review by the company shown in this application of any incidents or occurrences likely to result in malpractice allegation or claim. I agree to cooperate in the review of claims and incidents which apply to the coverage requested. Where applicable, I hereby consent to the review of my application by the committees appointed by my county or state professional association/society. I agree to cooperate with these committees. Applicable in AL, AR, DC, LA, MD, NM, RI and WV Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only. Applicable in KS Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA 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 fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN, VA, and WA Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. A Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. PRIVACY POLICY STATEMENT CANOPIUS US INSURANCE INC. Canopius US Insurance, Inc. wants you to know how we protect the confidentiality of your non-public personal information as well as how and why we use and disclose the information we have about you. The following describes our policies and practices for securing the privacy of our current and former customers. We may amend our privacy policy from time to time consistent with applicable privacy laws. INFORMATION WE COLLECT The non-public personal information that we collect includes, but is not limited to: •Information contained in applications or other forms that you and/or your authorized representatives submit to us, such as name, address and social security number. •Information we obtain from you and others in connection with insurance coverage we issue to you, including but not limited to, information about your transactions with our affiliates or other third parties, such as financial account balances and payment history. •Information we receive from insurance support organizations and consumer or other reporting agencies related to your credit-worthiness or credit history. Information obtained from a report prepared by an insurance support organization may be retained by the insurance support organization and disclosed to other persons. REASONS WE CAN DISCLOSE YOUR PERSONAL INFORMATION We do not disclose personal information about current or former customers to anyone, except as permitted by law. We do not share information we collect from consumer or credit reporting agencies with our affiliates or others without your consent unless such disclosure is permitted by law. We may disclose some or all of the personal information (other than information we receive from consumer or other credit reporting agencies) that we collect about you to companies that perform services or functions on our behalf or to other financial institutions with whom we have entered into joint agreements for the marketing of financial products or services. Our contractual agreements prohibit these third parties from disclosing or using your personal information other than to carry out the purposes for which we disclosed the information. We may disclose your personal information to affiliates, including insurance companies, or third parties, including insurance salespeople or insurance providers, when it is necessary to provide products and services you request or as otherwise permitted under applicable law. We may disclose information when the law requires or permits us to do so such as law enforcement and state regulatory agencies. CONFIDENTIALITY AND SECURITY We maintain physical, electronic and administrative safeguards designed to protect your personal information from unauthorized access. We limit access to your personal information to those employees and/or third parties who need such access in connection with providing products or services to you or for other legitimate business purposes. RIGHT TO ACCESS OR CORRECT YOUR PERSONAL INFORMATION As required by applicable law, we will afford you the right to: 1.Access your personal information; 2.Find out to whom your personal information has been disclosed; and 3.Request correction or deletion of your personal information. Where permitted by law, we may charge a reasonable fee to cover the costs incurred in responding to such request. All requests must be made in writing to the following address: ATTN: Privacy Compliance Canopius US Insurance, Inc. 200 S. Wacker Drive, Suite 950 Chicago IL 60606-5829 CONTACTING US If you have any questions about this privacy notice or would like to learn more about how we protect your privacy, please contact the agent or broker who handled this insurance. We can provide a more detailed statement of our privacy practices upon written request. I have read the statements above, understand their meaning, and agree.AgreeDon't Agree Name: Title: Email PhoneSubmitResetSubmission of this form is governed by our Terms of Use. Current Licenses:California–#0M08088ConnecticutColoradoIllinoisMassachusettsMichiganMissouriNevadaNew JerseyNew MexicoOklahomaOhioOregonWashington
