LIO Specialty – Life Science Supplemental Application

1. Applicant Information

Named Insured / Applicant Legal Name *

DBA / Trade Name (if applicable)

Entity Type *

Number of Years in Business *

Mailing Address

Mailing Address *

City *

State *

ZIP Code *

Risk Location

Same as mailing address

Enter the primary location where the insured's operations are conducted.

Street Address *

City *

State *

ZIP Code *

Primary Contact Name

Phone

Email Address

Website

Policy Effective Date *

Policy Expiration Date *

2. Coverage Requested

Lines of Coverage

CGL – Claims Made GL – Occurrence & Products/Completed Ops – Claims Made Products/Completed Ops Only – Claims Made

Expiring Coverage

New Venture (no prior insurance)

Expiring Carrier

Expiring Premium ($)

Expiring Deductible

Was the expiring policy written on a Claims Made basis?

Yes No

Is this a mid-term quote or is coverage currently lapsed?

Yes No

Has the applicant experienced a loss in the last five years for a coverage being requested?

Yes No

Optional Coverages

Hired Auto & Non-Owned Auto Liability

Stop Gap Employers Liability

Employee Benefits Liability

Limited Product Withdrawal Expense

Security Breach Expense Reimbursement

Hired & Non-Owned Auto Details

Estimated Annual Mileage Per Employee/Year *

Number of Employees Driving for Business *

Stop-Gap / Employers Liability Limits

Bodily Injury by Accident (each accident)

Bodily Injury by Disease (aggregate)

Bodily Injury by Disease (each employee)

Employee Benefits Liability Limits

Each Employee Limit

Aggregate Limit

Deductible

Limited Product Withdrawal Expense

Aggregate Limit *

Deductible Per Product Withdrawal *

Security Breach Expense Reimbursement

Aggregate Limit *

Each Event Deductible *

3. Business Description

Describe the Applicant's Operations in Detail *

Gross Sales History

Policy Year	Gross Sales ($)
Upcoming Annual (projected)
Current / Prior Year
2 Years Ago
3 Years Ago
4 Years Ago
5 Years Ago

Classification

Select the primary class code(s) that apply to this account. Percentages must total 100%.

Classification	% of Revenue
Nutraceuticals (2500)
Cosmetics (2601)
Total	0.0%

4. Product Information

Product Breakdown (must total 100%)

Enter the percentage of annual revenue represented by each product category.

Product Category	% of Revenue
Vitamins?A concentrated amount of substances or nutrients within a pill or capsule taken as a dietary supplement.
Protein Supplements?Supplements supporting muscles, bones, and the nervous system.
Bodybuilding Supplements?Dietary supplements commonly used by those involved in bodybuilding, weightlifting, mixed martial arts, and athletics for the purpose of facilitating an increase in lean body mass.
Energy Supplements?Supplements aiding in energy production.
Weight Loss Products?Supplements that aid weight loss.
Non-Compounded Herbs?Natural compounds from plants, leaves, bark, roots, seeds or flowers.
Compounded Herbs?Combining natural compounds from plants, leaves, bark, roots, seeds or flowers.
Sexual Enhancements?Supplements aiding in circulation and hormone production.
Topical Creams?Products applied to the body surfaces such as skin or mucous membranes.
Body Cleansers?Detox supplements that aid in removing toxins from the body.
Other
Total	0.0%

Describe Other Products *

Role (select all that apply)

5. Underwriting Questions

Quality Control

Complies with Good Manufacturing Practices (GMP)?

Yes No

Quality control and testing procedures in place?

Yes No

Formulas and designs reviewed / tested by outside labs?

Yes No

Program to withdraw known or suspected defective products from market in place?

Yes No

Require contract manufacturers to comply with GMP? *

Yes No

Current or previous product recall (voluntary or mandatory) / received warning letter from regulatory agency?

Yes No

Describe Recall / Warning Letter *

Labels & Advertising

Labels and advertising fully compliant with all applicable FDA and FTC regulations?

Yes No

Labels include disclaimers that the FDA has not evaluated claims and products are not intended to diagnose, treat, cure or prevent disease?

Yes No

Product labels / advertising make health claims for specific diseases or health-related conditions?

Yes No

Product labels clearly state appropriate dosages, warnings, known side effects and contraindications?

Yes No

Labels compliant with Prop 65 requirements?

Yes No

Outside legal counsel used to review and approve labeling and advertising?

Yes No

Products have similar names that may indicate intended for same use as FDA-approved drug?

Yes No

Products & Ingredients

Applicant sells products manufactured outside the U.S.?

Yes No

Making / selling products intended for children?

Yes No

Describe Children's Products *

Making / providing products for use in pre-natal or post-natal care?

Yes No

Describe Pre/Post-Natal Products *

Products contain CBD / Hemp?

Yes No

6. Fraud Notice & Declaration

⚠ NOTICE TO POLICYHOLDERS — FRAUD NOTICE (NTC FR01 10/21)

NOTICE TO APPLICANTS: 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 act, which is a crime, and may subject such person to criminal and civil penalties.

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND, AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS: 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.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who knowingly and with intent to defraud presents any written statement as part of an application for insurance that such person knows to contain materially false information commits a fraudulent insurance act.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information commits a fraudulent insurance act, which is a crime.

NOTICE TO MAINE APPLICANTS: 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 or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

FIRE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: 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 may be guilty of a fraudulent act, which may be a crime.

NOTICE TO PENNSYLVANIA APPLICANTS: 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.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. The undersigned authorized representative affirms that all information provided is accurate and complete to the best of their knowledge. I understand that coverage is not bound until confirmed in writing by LIO Insurance.

7. Signatures

Applicant / Authorized Representative

Name

Title

Applicant Signature

Date