Marijuana Liability Application

Please answer all questions completely. Completion of this application does not constitute coverage.

Agency/Broker Name(Required)

Agency/Broker Code

Conifer, White Pine or Sycamore Code

Untitled(Required)

Email(Required)

Phone

Business Name(Required)

Name on Facilities License(Required)

Business Address

Street Address Address Line 2 City State ZIP Code

Policy Effective Date

License Type

Cannabis Sales(Required)

Liability Limit(Required)

$50,000 Minimum

Is your client a member of one of our partner associations?

MiCIA - Michigan Cannabis Industry Association

Additional Information

Optional Attachments

Drop files here or

Accepted file types: pdf, docx, xlxs, Max. file size: 4 MB.

Example: Current policy, loss runs or underwriting information