medical marijuana application

8/6/2019 Medical Marijuana Application

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M A R K E l ~

o D EE RFIE LD IN SU RANC E C OM PANYo E SSE X IN SU RANC E C OM PANYo EV AN STO N IN SU RA NCE COMPA NYo M ARK EL AM ERICA N INSU RA NCE COM PANYo MARK EL IN SU RA NC E COMPA NY

VANTAGEi 9 NE 5 5 3 i i1 P l' O Rf &: t NS l!R .ANCE SEkV IC f: : S

2363 Mariner Square Dr, #240Alameda, CA 945011'.510-595-0900 F. 510-595-0930

APPLICATION FOR PHARMACYPROFESSIONAL LIABILITY INSURANCE

(Claims Made Basis)APPLICANT'S INSTRUCTIONS:1. Answer all questions. If the answer requires detail, please attach a separate sheet.

2. Application must be signed and dated by owner, partner or officer.3. Please do not complete application earlier than 45 days before proposed effective date of coverage.4. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.(PLEASE TYPE O R PR IN T IN IN K)

GENERAL INFORMATION

b. PrinclpalBusinessAddress: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Business Phone: (_)~~~~~ E-Mail Address: ~~~~~~_Website: ~~~~~~~~~_.

d. ~~e~bl~~d:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~_Please attach proforma business plan if this is a start-up.OPERATIONSa. Describe the nature of applicant's operations including types and percentage of services rendered:

%Retail ~~~~~~~~~~~~~~~~~~~~~~~~~~_Wholesale _~~~~~~~~~~~~~~~~~~~~~~~_Mail Order_~~~~~~~~~~~~~~~~~~~~~~~_Drug Benefit __ ~~~~~~~~~~~~~~~~~~~~~_Compounding ~~~~~~~~~~~~~~~~~~~~~~~_Other_~~~~~~~~~~~~~~~~~~~~~~~~~ __

Total (100%)b. Provide the following information for all of the states in which you are licensed:

State License No. Effective Date Expiration Date

c. Are all drugs dispensed FDA approved? Yes _No __ if no, please attach explanation.-30002-01 03/05 Page 1 of 6


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d. Complete the following information for each location you own.

(i) Has the Applicant implemented procedures to comply with the HIPAA Privacy Rule?(ii) Provide the name and title of the Applicant's Privacy Officer: _Our Business Associate Agreement is available at www.markelcorp.com.This is the only Business AssociaAgreement we will recognize.

Yes No

Name and Address Your Ownership % Description of Operations

e. Do you have any International operations? Yes _ No _f. Are any drugs imported? Yes _ No _ if yes, please attach explanation.g. Does licensed physician in State where services are rendered issue all prescriptions? Yes_ No_h. Is pharmacy in compliance with all local, state and federal laws that govern the manufacture, control, dispensing adistribution of prescription drugs? Yes No__i. Annual Number of prescriptions filledj. Annual Gross Receipts: (complete all applicable categories)

Last 12 Months Next 12 Months$_-----$_-----$_-----$_-----$_-----$_-----$_-----

k. Is the Applicant a "Covered Entity" under the Health Insurance Portability and Accountability Act of 1996 (HIPAPrivacy Rule? Yes _No_I. If yes,

From Prescription Sales: $From Sundries Sales: $From Medical Equipment Sales: $From Medical Equipment Rental: $From In Home Therapy: $Other: $TOTAL: $

. PROFESSIONAL SERVICESa. Do you provide mail order services? Yes No__

if yes, provide details of safety controls to assure a licensed physician authorizes prescriptions.Do you provide services to the following:Nursing Home Hospitals Extended Care Facility Correctional Facilities __ MCOs __if yes, please provide copy of contract.

c. Do you provide Pharmacy Benefit Management services, including any of the following: drug utilization revieformulary management and design, medical necessity review, credentialing review, pharmacy data and supportinservices. Yes Noif yes, please attach list of five (5) largest clients and provide copy of sample contract.

b.

d. Do you compound in bulk, manufacture or wholesale drugs or products? Yes __ No__if yes, are active ingredients purchased from chemical factories that have registered with the FDA? Yes_ No_

e. Do you provide specialized pharmacy services such as nuclear, veterinarian or other? Yes __ No __If yes, please provide details.

f. Are you a member of the Institute for safe Medication Practices (ISMP)? Yes __ No __g. Please indicate the type of medical supplies and/or equipment you sell or lease or repair for others:

I ANNUAL SALES I LAST 12 I CURRENT 12TYPE-30002-01 03/05 Page2 of6
http://www.markelcorp.com.this/http://www.markelcorp.com.this/


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MONTHSONTHS

4. STAFFa. Number Type of Profession Number Type of Profession

Pharmacists E3 Pharmacy TechniciansRNs Respiratory TherapistsPhysicians Other

b. Are all of the above individuals licensed in accordance with applicable state and federal regulations? Yes D Noc.

i f no, please attach an explanation.Do you supervise or contract with any individual other than your own employees?if yes, please provide explanation of responsibilities and relationship to the entity, whichemploys these individuals. _

YesD NoO

d. Do you require all contracted staff (if any) to carry their own Professional Liability Insurance andsecure Certificates of Insurance as evidence of such coverage? YesCo0

e. What limits of liability of Professional Liability are required? _5. RISK MANAGEMENT

a. Are telephone orders only taken by a~rmacist from authorized professional staff and repeated back toprescriber for verification? Yest::;l NoWIAre products with known look-alike drug names stored separately and not alphabetically? YesWlNot::;lDo you have access to drug information (l.e., Drug Facts and Comparisons, Micromedex etc.)? Yes[l NoDDo you perform pediatric dose range checks? Yes CI No ICJHow do you detect drug contraindications, interactions, duplications against medical history and other prescribdrugs?What safety controls are in place to address problematic or look-alike drug names, packaging, or labelin

b .c.d.e.f.g. Are ,pe~lial alerts built into the system concerning problematic or look-alike drug names, packaging, or labelinYes No_O_

What criteria are established (i.e. targeted high-alert drugs, patient population) to trigger required medicaticounseling (l.e, alert tag on bag)? -==_==- _Are all prescriptions dispensed with current written instructions? Yes_c::::jNo..Cil.Do you accept electronic prescriptions? YesD Ndnl if yes, what safety controls are in place to assuprescriptions are prescribed by licensed physicians?How are drug wastes and expired drugs disposed? _

h.

Lj.k .

6. APPLICANT HISTORY/CLAIMSa. Have you or any of your employees:

(i) Ever been the subject of disciplinary or investigative proceedings or reprimand by a governmentaladministrative agency, hospital or professional association? Yes.DL No ~ I I(ii) Ever been convicted for an act committed in violation of any law ordinance other than traffic offense

Yes CI NoCI if yes, attach disciplinary agency documents.SM-30002-01 03/05 Page3 of6


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Policy Limits ofInsurance Carrier Number Liability

(iii) Ever been treated for alcoholism or drug addiction? Yes CJ Noc:J(iv) Ever had any state professional license or license to prescribe or dispense narcotics, refused, rusrNn!ledrevoked, renewal refused or accepted only on special terms or ever voluntarily surrendered? Yes 0if yes, attach disciplinary agency documents.(v) Ever had any insurance compan~Lloyd's cancel, decline, refuse to renew or accept only on special term

their malpractice insurance? Yes_W1_ NoCb. Please list Professional Liability insurance carried for each of the past ten years. IF NONE, STATE NONE.

Was this aClaims MadePolicy Form?Yes No~

Deductibleill ..oy} Inception ExpirationPremium Mo'/DaylYr. Mo'/DaylYr. RetroDate

c. Has any claim or suit been brought against you and/or any of your employees? Yes t:JI No I:J if yes, providethe following information:1. If a current loss summary is available from the present and previous carrier, please attach a copy.2. If a loss summary is not available, attach a Supplemental Claim Information Form showing the following

information for each claim:(i) Date of event and date claim was reported to the insurance company.(ii) Description (cause) of loss or claim.(iii) Location of loss.(iv) Current status (open or closed)(v) Paid amount and current reserve amount.

3. Are you aware of any circumstances which miv r1sult in a malpractice claim or suit being made or broughtagainst you or any of your employees? Yes_ No I:J if yes, attach details.d. Please list prior General Liability insurance carried for each of the past five years. If none, state "NONE".

Was this aPolicy Limits of Deductible Inception Expiration Claims Made RetroInsurance Carrier Number Liability ill ..oy} Premium Mo'/DaylYr. Mo'/DaylYr. Policy Form? Date

~~7. GENERAL LIABILITY

a. Please complete the following for each of your facilities if you desire General Liability insurance:Parking Lot or

Location Name and Description of Garage Maintained Adjacent SquareNumber Location Address Ty~e of Facility by Insured? Ex~osure? Footage

(i) DYes DNo DYes DNo(ii) [JIYes DlNo DYes DNo

DYes DNo DYes DNo

b. Please complete the following for each location:(i) Year built(ii) Year Remodeled(iii) Number of Stories(iv) Construction: Frame, Brick, Concrete

SM-30002-01 03/05 Page4 of6


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(v) Percentage of Building Occupied by Insured(vi) Other Occupancy(vii) Location Number

c. Is the Building Equipped with:(i) Complete Sprinkler System? 0Yes DN(ii) At Least Two Clearly Marked Exits at Each Floor? 0Yes DN(iii) Self-Closing Fire Doors on Each Floor? 0es B N(iv) Automatic Fire Alarm System Connected to Local Fire Department? BYes 0(v) Smoke Detectors? . Yes B N(vi) Emergency Electrical System? 0Yes N(vii) Heat Sensors? BYes B N(viii) Fire Escape(s)? . Yes N(ix) Posted Emergency Evacuation Procedures? DYes 8 N(x) Properly Maintained Fire Extinguishers? [[]Yes 1 NIs a formal written safety program in place? DYes D IN(if yes, please attach a copy of the safety program.)Are written procedures in effect for incident reporting? C J 1 Yes D NAny exposure to flammables, explosive, chemicals? [] Yes DNAny catastrophe exposure? 0Yes [DNoAny exposure to radioactive materials? 0es D NDo operations involve storing, treating, discharging, applying, disposing, or transportinghazardous materials? DYes DNMachinery or equipment loaned or rented to others? DYes 0NAre there any elevators or escalators owned by you? DYes 0Nif yes, please indicate model and if the elevator and/or escalator is serviced by you under amaintenance contract. .Any parking facilities owned/rented? ; IOIYes D NRecreation facilities provided? eYes DNIs there a swimming pool on the premises? DYes D NSporting or social events sponsored? I[]Yes D I N10 Year General Liability Loss History (attach further sheets if needed)

d.

e.f.g.h.i.

k.

I.m .n.o.

p.Date of Date Claim

Occurrence MadeAmount

Descriptionof Loss

Amount ofof LossReserved

orClosed (

AmountExpenses

PaidAmount ofof Loss

ReservedOpen (0)ExpensesReserved

q. Are you aware of any circumstances that may result in a general liability claim or suit being madebrought against you? .. ..............0Yes 0 Nif yes, please attach a Supplemental Claim Form

SM-30002-01 03/05 Page50f6


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NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage onCLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.ARRANTY: I/We warrant to the Insurer, that I understand and accept the notice stated above and that the informatioontained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should thnsurer evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information fromy prior insurer to the underwriting manager, Company and/or affil iates thereof.

gnature of Applicant Date

me of Applicant Title (Officer, partner, etc.)

IGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, bne copy of this application will be attached to the policy, if issued.

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