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Marijuana Liability Application

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

Marijuana Liability Application

Agency Information

Agency Name(Required)

Agency Code

Agency Contact Name(Required)

Agency Contact Email(Required)

Agency Contact Phone

Applicant Information

Business Name(Required)

Name on Facilities License(Required)

Business Contact Name(Required)

Business Contact Email(Required)

Business Contact Phone(Required)

Business Address

Street Address Address Line 2 City State ZIP Code

Policy Effective Date

MM slash DD slash YYYY

Underwriting Information

License Type

Cannabis Sales(Required)

Liability Limit(Required)

$50,000 Minimum

Is the applicant a member of an industry association?

Yes

No

What industry association is the applicant a member of?

MiCIA - Michigan Cannabis Industry Association*

Other

*Members may be eligible for premium discounts

If available, please provide the applicants membership number

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

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