MEDICAL MARIJUANA DISPENSARY SUPPLEMENTAL APPLICATION
(COMPLETE FOR EACH LOCATION ALONG WITH ACORD . IF MORE THAN ONE LOCATION OR IF GROWING
OPERATIONS ARE SEPARATE FROM DISPENSARY, PLEASE COMPLETE SUPPLEMENT FOR EACH LOCATION)
APPLICANT NAME:_____________________________________________________________________
MAILING ADDRESS: ____________________________________________________________________
LOCATION ADDRESS: ___________________________________________________________________




Is this location occupied as a: DISPENSARY? WAREHOUSE? GROWING OPERATION?
Is there delivery OFF PREMISES?
Yes
No
Please describe the CRIME area of this location?
Low
Medium
High
Does the Applicant occupy the entire building?
Yes
No
If answered No, are there connecting doors to adjacent units?
Yes
No
If answered Yes, how are the connecting doors secured? i.e. deadbolts, alarms, etc._________
______________________________________________________________________________

Please indicate ALL SECURITY SYSTEMS/DEVICES utilized:
Central Station Burglar Alarm
Central Station Fire Alarm
Metal Doors
Door Intercom
Interior Motion Detectors
Gated Doors
Gated Windows
Hold-Up/Panic Button
Exterior Camera(s)
Interior Video Camera(s)
Metal Detector
Security Vestibule/Mantrap
Safe Info: Weight? ____Ton ULTL _____ Fire Resistive? Yes No Bolted to floor? Yes No
OTHER SECURITY(Please describe)__________________________________________________







DOES THE APPLICANT HAVE ANY WEAPONS ON PREMISES?
Yes
No
DOES THE APPLICANT HAVE A WRITTEN PLAN OR MANUAL THAT DESCRIBES BUSINESS
SECURITY PROCEDURES, INCLUDING WHAT TO DO IN THE EVENT OF ROBBERY OR OTHER
CRIME?
Yes
No
ARE EMPLOYEES INSTRUCTED TO COOPERATE AND OBEY THE ROBBER’S INSTRUCTIONS AND
NOT TO RESIST?
Yes
No
HOW MUCH INVENTORY IS DISPLAYED TO CUSTOMERS? 0-5% 6-10% 11-25% Over 25%
How much inventory is kept on premises during BUSINESS HOURS?
$_______________
How much inventory is kept on premises during NON-BUSINESS HOURS? $______________
Do you keep written records of all product sold, including date of sale and type(s) of product
sold?
Yes
No





Does the Applicant utilize EMPLOYEES as: Door identification checkers? Yes
No
Bouncers or security guards? Yes
No
If Yes, are they armed?
Yes
No
Does the Applicant utilize PRIVATE SECURITY GUARDS?
Yes
No
If Yes, are they armed?
Yes
No
Does Applicant keep verification of the security company’s GL insurance on record that also
names the Applicant as an Additional Insured?
Yes
No
After business hours, is all inventory stored in a locked safe?
Yes
No
Do you grow Marijuana or other cannabis plants on these premises?
Yes
No
If Yes, please complete the “Growing Operations” supplement below. If growing operations
located at a separate location, please complete a separate MEDICAL MARIJUANA DISPENSARY
SUPPLEMENTAL APPLICATION.
Are there any other operations besides dispensing cannabis,, i.e. acupuncture, selling herbal
remedies, massage, etc.
Yes
No
If Yes, Describe: _________________________________________________________________
______________________________________________________________________________
GROWING OPERATIONS SUPPLEMENT
(COMPLETE FOR GROWING OPERATIONS)















Total number of plants at insured location? _________________________________________
Number of times per year an average plant will be harvested? __________________________
Average wholesale price per lbs of marijuana? _______________________________________
Average amount of dried finished stock from each plant per harvest? _____________ ounces.
Your estimated inside sales per year? ______________________________________________
Your estimated outside sales per year? _____________________________________________
Square foot of grow area? ________________________________________________________
Do you use flow meters or water timers to prevent flooding?
Yes
No
Is the grow located above the ground floor?
Yes
No
Does the Applicant’s employees visit the site on a daily basis?
Yes
No
How do you maintain a constant temperature in the facility? ___________________________
Is the Applicant or employees armed with any type of weapon at this site?
Yes
No
Do you utilize security guards at this site?
Yes
No
If Yes, are the security guards employees?
Yes
No
Has the growing facility been inspected by a licensed electrician who has determined that the
power supply of the building is adequate and safe for the power consumption needs of your
grow operations?
Yes
No