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Vitamins, Supplements & Nutraceuticals

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Your Information

Applicant Company:*
Contact Name:*
First Last
How did you hear about Ashlin Hadden Insurance Agency*
Business Premise Address

Street Address*
City*
State*
Zip Code*
Additional Info

Telephone:*
Fax Number:
Email:*
Website:*
What is your Amazon Seller ID / Merchant Token? This policy can only accommodate one Amazon Seller account.
Please state when your company was established (month/day/year):*
MM slash DD slash YYYY
Please state the number of full-time employees:*
Please state the number of part-time employees:*
FEIN#:*
Applicant is a:*
- Corporation
- Partnership
- Sole Proprietorship
- LLC
Is the Applicant controlled by, owned by, or commonly owned, affiliated, or associated with any other organization?*
- Yes
- No
If yes, please provide details:*
Product #1 for which the Applicant wants coverage:*
For Product or Service #1, Applicant acts as which of the following:*
- Manufacturer
- Wholesaler
- Retailer
- Importer
- Manufacturer's Rep
Product #1 - Number of Years*
Product #1 - Percentage of Gross Receipts*
Please enter a number from 0 to 100.
Product #1 is sold to:*
- Wholesaler
- Retailer
- Consumer Direct
Are there other products the Applicant wants coverage for?*
- Yes
- No
Product #2 for which the Applicant wants coverage:*
For Product or Service #2, Applicant acts as which of the following:*
- Manufacturer
- Wholesaler
- Retailer
- Importer
- Manufacturer's Rep
Product #2 - Number of Years*
Product #2 - Percentage of Gross Receipts*
Please enter a number from 0 to 100.
Product #2 is sold to:*
- Wholesaler
- Retailer
- Consumer Direct
Are there other products the Applicant wants coverage for?*
- Yes
- No
Product #3 for which the Applicant wants coverage:*
For Product or Service #3, Applicant acts as which of the following:*
- Manufacturer
- Wholesaler
- Retailer
- Importer
- Manufacturer's Rep
Product #3 - Number of Years*
Product #3 - Percentage of Gross Receipts*
Please enter a number from 0 to 100.
Product #3 is sold to:*
- Wholesaler
- Retailer
- Consumer Direct
Are there other products the Applicant wants coverage for?*
- Yes
- No
Product #4 for which the Applicant wants coverage:*
For Product or Service #4, Applicant acts as which of the following:*
- Manufacturer
- Wholesaler
- Retailer
- Importer
- Manufacturer's Rep
Product #4 - Number of Years*
Product #4 - Percentage of Gross Receipts*
Please enter a number from 0 to 100.
Product #4 is sold to:*
- Wholesaler
- Retailer
- Consumer Direct
Estimated annual gross receipts from all products and services listed above for the coming year*
Annual gross receipts from all products and services listed above for the last 12 months:*
Annual gross receipts from all products and services listed above for the prior year:*
Is the Applicant presently considering any change in the mix of products, including adding new products or services for the coming year?*
- Yes
- No
If yes, please provide details:*
Has the Applicant discontinued or is it considering discontinuing any product or service listed above?*
- Yes
- No
If yes, please provide details:*
Do any products, ingredients, or components thereof originate from outside of the United States?*
- Yes
- No
Please copy and paste your manufacturers name and address.*
If yes, please specify the country(ies) of origin:*
If yes, please specify the name of each organization manufacturer, distributor, or supplier:*
Do others manufacture or package products under the Applicant’s name or label?*
- Yes
- No
If yes, please provide the name(s) and address(es) of contract manufacturer(s):*
Does the Applicant manufacture or package products for others under their name or label?*
- Yes
- No
If yes, please explain:*
Does the Applicant have a quality control and testing procedure?*
- Yes
- No
If yes, how long does the Applicant keep quality control and testing records?*
Do you comply with Good Manufacturing Practices (GMP)?*
- Yes
- No
If you are a distributor, do you require your contract manufacturer to comply with GMP?*
- Yes
- No
- Not a distributor
Do all records show to whom and the date each product was sold?*
- Yes
- No
Does the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?*
- Yes
- No
Who designs the Applicant’s products?*
Are product designs reviewed, tested and verified by others?*
- Yes
- No
Do you have any past, present, or planned association with any of the following?*
(Mark all that apply.)
- Germander
- Yohimbe
- Gamma-Hydroxybutyrate (GHB); Gamma-Butyrolactone (GBL); 1, 4 Butanediol (BD)
- Aristolochia spp., Aristolochia, Aristolochic acids, Aristolochia fanghi, Aristolochia spp., Asarum [ ] spp., Bragantia spp., Clematis spp., Akebia spp., Cocculus spp., Diploclisia spp., Menispernum spp., Sinomenium spp., Mu Tong, Fang Ji, Guang Fang Ji, Fang Chi, Kan-Mokutsu, and any adulterated botanicals, botanical derivatives, or other products that contain aristolochic acid, aristolochic acid derivatives, or aristolochic acid extracts.
- Lobelia
- Jin Bu Haun
- Ephedra Sinica, Ephedra. E. equisetina, Ma Huang, Ephedra Alkaloid, Pseudoephedrine, Ephedrine or any other Ephedra derivatives or extracts.
- Stephania, Stephania spp, or any adulterated botanicals, botanical derivatives, or any other products that contain Stephanie, or any Stephanie derivatives or extracts.
- Magnolia, or any adulterated botanicals, botanical derivatives, or any other products that contain Magnolia, or any Magnolia derivatives or extracts.
- Kava, ava, ava pepper, awa, kava root, kava-kava, kawa, Piper methysticum Forst. f, Piper Methysticum G. Forst, rauschpfeffer, intoxicating pepper, kava kava, kava pepper, kawa kawa, kawa-kawa, kew, Piper methysticum, sakau, wurzelstock, yangona.
- Chaparral Comfrey (Pyrrolizidine Alkaloids)
- DMAA, 1,3 Dimethylamylamine, Dimethylamylamine, Methylhexanamine
- Glyburide, unla beled glyburide, Liqiang 1,Liqiang 4, Liqiang Xiao Ling
- Liqiang Xiao Ke Ling (Liqiang Thirst Quenching Efficacious)
- Animal tissue in any form including glands, and/or extracts
- Fenfluramine
- Glyburide
- Herbal Ecstasy
- Herbal Phen-Fen
- L-tryptophan
- Ma Huang
- Redux
- Bitter Orange (Citrus Aurantium)
- None
Do you have any past, present, or planned association with any derivatives of any of the above ingredients?*
- Yes
- No
If yes, please list:*
Please list all of your products that include any of these ingredients checked off; attach product labels for each product listed below, and your total projected sales for each of these products.*
(Attach separate sheet if necessary.)
Do any products contain steroids or steroid-like substances, or claim to increase testosterone?*
- Yes
- No
If yes, please provide details:*
Do you promote any of your herbal products for use in children?*
- Yes
- No
Do you provide any products for use in pre-natal or post-natal care?*
- Yes
- No
Do any of your dietary supplements carry USP (United States Pharmacopeia) or NF (National Formulary) seal on the label?*
- Yes
- No
Does the Applicant have a specific program to withdraw known or suspected defective products from the market?*
- Yes
- No
Has the Applicant ever recalled or is it considering recalling any product?*
- Yes
- No
If yes, please explain:*
Have any of the Applicant’s products or ingredients or components thereof ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any governmental, quasi-governmental, administrative, regulatory or oversight body?*
- Yes
- No
If yes, please provide details:*
Limits of Liability requested:*
Deductible:*
The company does not guarantee to offer any of the above limits and/or deductibles.
Does the Applicant currently have Product Liability insurance?*
- Yes
- No
Insurance Company:*
Limits of Liability:*
Deductible/SIR:*
Premium:*
Expiration Date:*
MM slash DD slash YYYY
Retroactive/Prior Acts Date:*
MM slash DD slash YYYY
Has any insurer declined, canceled, or nonrenewed any Product Liability insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?*
- Yes
- No
If yes, please provide details:*
Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last 5 years?*
- Yes
- No
If yes, provide 5 year loss history for all claims, including any predecessor. Attach a description of any loss greater than $5,000.
Year #1:*
Number of Claims - Year #1:*
Total Amounts Paid - Year #1:*
Amount Reserved - Year #1:*
Total Incurred - Year #1:*
Date of Loss Info - Year #1:*
MM slash DD slash YYYY
Year #2:*
Number of Claims - Year #2:*
Total Amounts Paid - Year #2:*
Amount Reserved - Year #2:*
Total Incurred - Year #2:*
Date of Loss Info - Year #2:*
MM slash DD slash YYYY
Year #3:*
Number of Claims - Year #3:*
Total Amounts Paid - Year #3:*
Amount Reserved - Year #3:*
Total Incurred - Year #3:*
Date of Loss Info - Year #3:*
MM slash DD slash YYYY
Year #4:*
Number of Claims - Year #4:*
Total Amounts Paid - Year #4:*
Amount Reserved - Year #4:*
Total Incurred - Year #4:*
Date of Loss Info - Year #4:*
MM slash DD slash YYYY
Year #5:*
Number of Claims - Year #5:*
Total Amounts Paid - Year #5:*
Amount Reserved - Year #5:*
Total Incurred - Year #5:*
Date of Loss Info - Year #5:*
MM slash DD slash YYYY
Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, defect or suspected defect which may result in a Products Liability claim?*
- Yes
- No
If yes, please provide details:*
Are business operations operated out of a personal residence?*
- Yes
- No
Are you currently aware of any environmental conditions which could reasonably be expected to give rise to a claim?*
- Yes
- No
If yes, please describe:*
Are there any above ground or underground storage tanks of capacity greater than 250 gallons located on the premises?*
- Yes
- No
If yes, please attach Tank schedule.
If yes, do these tanks meet EPA 1998 upgrade requirements?*
- Yes
- No
Are any goods, products, or materials that are stored or used for any purpose at the insured location classified as being of a flammable, combustible or explosive nature?*
- Yes
- No
If yes, please provide a listing of all goods, products or materials with a description as to how stored any fire and/or spill prevention procedures and control measures (i.e., sprinkler system) in place below:*
Has the Applicant during the last 5 years been cited and/or prosecuted for contravention or violation of any standard or law relating to any release from your premises of any substance into sewers, rivers, seas, air or onto land?*
- Yes
- No
If yes, please describe:
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