Fillable BEAUTY SHOP/BARBER SHOP AND DAY SPA LIABILITY APPLICATION (RT Specialty)

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BEAUTY SHOP/BARBER SHOP AND DAY SPA LIABILITY APPLICATION (RT Specialty)

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The BEAUTY SHOP/BARBER SHOP AND DAY SPA LIABILITY APPLICATION (RT Specialty) form is 5 pages long and contains:

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  • 48 check-boxes
  • 143 other fields

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File type: PDF

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
BEAUTY SHOP/BARBER SHOP AND DAY SPA LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Web site Address:
Agency Name:
Agent:
Address:
E-mail:
Phone:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Applicant is:
a. Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
b. Owner Tenant
c. Barber Shop Beauty Parlor Day Spa Dental Spa Medical (Medi) Spa Tanning Salon
Limits Of Liability & Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products & Completed Operations Aggregate $
Personal & Advertising Injury (any one person or organization) $
Each Occurrence $
Damage to Premises Rented to You (any one premises) $
Medical Expense (any one person) $
Errors & Omissions Coverage Each Claim
(Included up to General Liability Limits) Aggregate
$
$
Sexual and/or Physical Abuse Coverage
$50,000/$100,000 (included)
$100,000/$300,000
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
BBS-APP-1 (9-12) Page 1 of 5
Submit Application
1. Name of business (D/B/A):
2. Part occupied by applicant:
3. How long has applicant been in business? years
4. Number of operators:
Full-time hair and/or manicurist: Part-time hair and/or manicurist (less than twenty [20] hours per week):
Aestheticians: Masseuses:
5. Total gross sales: $
6. Are all operators licensed? ...................................................................................................................... Yes No
7. Are records kept of patrons’ permanent waves and hair dyes? .......................................................... Yes No
8. State methods used in permanent hair waving (electric, cold wave, machineless, other):
9. Does applicant manufacture, mix, blend or repackage products sold for use on or off premises? Yes No
If yes, advise receipts and explain:
10. Are any operations performed away from the applicant’s premises? ................................................. Yes No
If yes, explain:
11. Number of:
Barber Shop chairs: Saunas: Tanning booths:
Hot tubs/spas: Swimming pools: Tanning spray on booths:
Hydromassage beds: Tanning beds: Toning beds:
12. Are any of the following exposures included in the applicant’s operation?
Beauty schools/classes Makeovers/Facials
Body piercing (other than ear piercing) Manicures/Pedicures
Body wraps Microdermabrasion; receipts: $
Botox or other cosmetic injections Nail sculpting
Chemical peels; receipts: $ Permanent cosmetics; receipts: $
Chiropody Plastic surgery
Colon hydrotherapy Podiatry detoxification
Ear candling Tattoos
Ear piercing Teeth whitening
Electrolysis Vein treatments
Face lifting Wig application
False lashes Waxing—hot/cold
Hair implants Other (describe):
Laser hair removal; receipts: $ Other (describe):
13. Has any operator had a previous claim or pending allegations for alleged malpractice, error or
mistake? .....................................................................................................................................................
Yes No
If yes, explain:
BBS-APP-1 (9-12) Page 2 of 5
14. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
15. During the past three years, has any company ever canceled, declined or refused similar insur-
ance to the applicant? (Not applicable in Missouri) .................................................................................
Yes No
If yes, explain:
16. Does applicant have other business ventures for which coverage is not required? ......................... Yes No
If yes, explain and advise where insured:
17. Additional Insured Information:
Name Address Interest
18. Prior Carrier Information:
Year:
Year:
Year:
Carrier
Coverage
Occurrence or Claims Made
Total Premium
19. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior three years.
Check if no losses last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or Closed)
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
BBS-APP-1 (9-12) Page 3 of 5
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable
from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony in the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (Applicable in Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
BBS-APP-1 (9-12) Page 4 of 5
NOTICE TO NEW YORK APPLICANTS (Other than automobile): Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: __________________________________________________________________ DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
BBS-APP-1 (9-12) Page 5 of 5
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BEAUTY SHOPBARBER SHOP AND DAY SPA LIABILITY APPLICATION (RT Specialty)

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Completed 13 December 2020

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