Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Name *

First Name

Last Name

Phone Number *

(###)

###

####

The date your company was established *

MM

DD

YYYY

Are you presently considering any change in the mix of products, including adding new products or services for the coming year?

Yes

No

Have you discontinued or are you considering discontinuing any product listed above?

Yes

No

Do any products, ingredients, or components thereof originate from outside of the United States?

Yes

No

Do others manufacture or package under your name or label?

Yes

No

Do you manufacture or package products for others under their name or label?

Yes

No

Do you have quality control and testing procedures in place?

Yes

No

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

N/A

Do all records show the date and to whom each product was sold?

Yes

No

Do you require certificates of insurance evidencing products liability insurance from suppliers or manufacturers?

Yes

No

N/A

Are product designs reviewed, tested, and verified by others?

Yes

No

Do any products contain steroids or steroid-like substances, or claim to increase testosterone?

Yes

No

Do you promote any of your herbal products for child use?

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 United States Pharmacopeia (USP) or National Formulary (NF) seal on the label?

Yes

No

Do you have a specific program to withdraw known or suspected defective products from the market?

Yes

No

Have you ever recalled a product or are you considering recalling any product?

Yes

No

Have any of the applicants products, 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 board?

Yes

No

Is product liability insurance currently in place? *

Yes

No

Has any insurer declined, cancelled, or nonrenewed your product liability insurance? *

Yes

No

In the recent five (5) years, has the applicant been subject to any liability claims, lawsuits or demands for damages, or, after inquiry, is the applicant or any of its principals or employees aware of any circumstances or incidents which may result such a claim? *

Yes

No

In the recent five (5) years, has the applicant voluntarily or involuntarily recalled or withdrawn, or considered recalling or withdrawing, any product for any reason? *

Yes

No

In the recent five (5) years, has the applicant received or become aware of a Serious Adverse Event Report, FDA Warning Letter, FTC Advisory Letter or any other complaint or notice of violation from any governmental agency or industry regulatory body concerning your business activities or products?

Yes

No

Does the applicant import any dietary supplement products or ingredients that are drop shipped directly by the foreign manufacturer or supplier to the applicant's customer? This does not apply to drop shipments directly from manufacturers in the USA to the applicant's customers.

Yes

No

Would you like Hired / Non-Owned Automobile Coverage to be included as an option?

Yes

No

Contact Name *

First Name

Last Name

Phone Number *

(###)

###

####

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Acts As A(n) *

Manufacturer

Wholesaler

Retailer

Importer

Manufacturers Rep.

Other

In the recent five (5) years, has the applicant been subject to any liability claims, lawsuits or demands for damages, or, after inquiry, is the applicant of any of its principals or employees aware of any circumstances or incidence which may result in such a claim? *

Yes

No

In the recent five (5) years, has the applicant voluntarily or involuntarily recalled or withdrawn, or considered recalling or withdrawing any product for any reason? *

Yes

No

In the recent five (5) years, has the applicant received or become aware of a Serious Adverse Event Report, FDA warning Letter, FTC Advisory Letter or any other complaint or notice of violation from any governmental agency or industry regulatory body concerning your business activities? *

Yes

No

Does the applicant import dietary supplement products or ingredients that are drop shipped directly by the foreign manufacturer or supplier to the applicant's customer? This does not apply to drop shipments directly from manufacturers in the USA to applicant's customers. *

Yes

No

Would you like Hired / Non-Owned Automobile Coverage to be included as an option?

Yes

No

Contact Name *

First Name

Last Name

Phone Number *

(###)

###

####