Fillable SALON/PERMANENT MAKEUP APPLICATION (Special Risks)

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SALON/PERMANENT MAKEUP APPLICATION (Special Risks)

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  • 36 check-boxes
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SALON/PERMANENT MAKEUP APPLICATION
Version: 10/2019 Page 1
Applicant Name: __________________________________________ Phone Number: ________________________________________
Business Name: _________________________________________________________________________________________________
Email Address: ___________________________________________ Website: ______________________________________________
Your Mailing Address: ___________________________________________________________________________________________
City: _______________________________________ State: _____________________________ Zip code: ______________
Your Business Address (1):________________________________________________________________________________________
City: _______________________________________ State: _____________________________ Zip code: ______________
County: ____________________________________________ Square Footage: ___________________________________
Your Business Address (2): ________________________________________________________________________________________
City: _______________________________________ State: _____________________________ Zip code: _____________
County: ____________________________________________ Square Footage: ___________________________________
Business operated as: ☐ Corporation ☐ LLC ☐ LLP ☐ Partnership ☐ Individual ☐ Independent Contractor
How long have you been in business? ________________________ Annual gross receipts from all operations? _________________
Are you in compliance with all city, county, state ordinances? ☐ Yes ☐ No
Do you need General Liability? ☐Yes ☐No If no, what Company insures your General Liability coverage? _____________________
Are you required to name any other person or entity as an Additional Insured on your Policy? ☐ Yes ☐ No
a. If Yes, Please provide Name and Address: ____________________________________________________________________
b. What is the interest of the Additional Insured? ☐Landlord ☐City or Government Agency ☐Lessor ☐Franchisor
☐Other: ______________________________________________________________________________________________
c. Does the additional Insured require the following: ☐Primary/ Non Contributory Wording ☐Waiver of Subrogation
Do you offer any treatments that include topical CBD/Hemp products?
☐Yes ☐ No
Do you sell any CBD/Hemp Products?
☐Yes ☐ No
Gross receipts: ___________
Products Liability needed for take home products sold by you
☐Yes ☐ No
Gross receipts: ___________
Do you sell non - beauty related products?
☐Yes ☐ No
If Yes, Describe: ______________
Do you private label products for sale?
☐Yes ☐ No
If Yes, requires separate application
Indicate number in your facility:
Saunas/Steam Rooms
______________
Soaking Pools:
______________
______________
Foot Detox Units:
______________
Oxygen Inhalation Devices:
______________
______________
Schedule of Services
# of People
Performing
Total Number of People at Facility:
Manicurist: Nails and Related Services
Beauticians and/or Barbers: Hair, Eyebrow Tinting
Cosmetologist: Topical Makeup, Eyelash & Eyebrow Extensions/Tinting, Threading, Waxing, Sugaring (includes Hair & Nails)
Massage Therapist: Massage, Body Wraps, Endermologie, Reiki
Aesthetician: If Yes, Mark ALL that apply
☐ Spray Tanning
☐ Electrology
☐ Medical Peels
☐ Facials/Aesthetic Grade Peels
☐ Ear Candling
☐ Microdermabrasion
☐ Dermaplaning
☐ Aesthetic Radio Frequency
☐ Ultrasound
☐ LED/Microcurrent
☐ Wart Removal
☐ Microneedling under 1.0 Deep
☐ Skin Tag Removal
☐ Cryo Spot Treatment
☐ Ear Piercing
☐ Microneedling over 1.0 Deep
☐ Non-Needle, Non-Prescription Spring Pressure Treatments
☐ Aesthetic Plasma Services
☐ Body Contouring/Cellulite Reduction and Name of Device Used:
SALON/PERMANENT MAKEUP APPLICATION
Version: 10/2019 Page 2
Permanent Makeup Section: Complete for EACH technician
Check Here If not NEEDED ☐
Name of Technician to be covered: __________________________ Years of Experience: ___________________________________
Pick which service (s) you will be performing:
☐Permanent Makeup: eyeliner, eyebrows, microblading, lips, lipliner, nipple areola
☐Microblading: Eyebrows Only
☐Pigment Removal (Not including touch ups) Specify Product: ________________________________________________________
Advanced Services (Additional Premium & Training Required): ☐ Scar Camouflage
☐Bald Spot Repigmentation
☐Cheek Blush
Total number of procedures done including at school: _______________________________________________________________
Training:
Total Number of Hours of In Person:
Total Number of Hours of Online:
Name of School
Date(s) Attended
________________
_________________
____________
__________
Information About Your Profession:
Do you have everyone sign a Consent Form and complete a Medical History Form
☐Yes ☐ No
☐ I am submitting my own forms
☐ I will use PPIB approved forms
Do you take before and after photos of all work?
☐Yes ☐ No
Do you schedule a follow up appointment after each procedure?
☐Yes ☐ No
Are all pigments/removal products you use from US or Canada manufacturers and/or EU standards?
☐Yes ☐ No
Do you EVER reuse needles?
☐Yes ☐ No
Is all your equipment pre – sterile, one time use?
☐Yes ☐ No
Property Section: Complete for EACH Location
Check Here if not NEEDED ☐
Age of Building: ______________________
Construction: _____________________
Number of stories: _____________________
If building is over 20 years old, when were the following upgraded? (*) information required
*Roof: _____________________
*Plumbing: _________________
*Wiring: ___________________
Sprinklers: ☐Yes ☐ No
*Is there a Central Station Burglar Alarm:
☐Yes ☐ No
Is the alarm inside your unit and in your control? ☐Yes ☐ No
Other Occupancies in building? (describe): __________________________________________________________________________
Adjoining Occupancies:
Left:_________________________
Right: ________________________________
Approximate distance from fire station: _______________________
Distance from fire hydrant: ______________________________
Do you sell or use jewelry?
☐Yes ☐ No
If Yes, Jewelry Value ($): ____________________________________
Name and address of Loss Payee: __________________________________________________________________________________
Coverage Desired:
Contents:
$:_______________________________
Tenant Improvements:
$: _______________________________
Building:
$: _______________________________
Do you own the Building?
☐Yes ☐ No
Business Interruption:
Amt Per Month: $: _________________
Months to be covered: ____________________
Sign:
$: _______________________________
Optional Coverages
Do you want coverage for Contingent Business Income?
☐Yes ☐ No
$10K limit (Off Premise, Power Outage)
Do you want coverage for the Coverage Extension
☐Yes ☐ No
$15K Total: Equipment Breakdown, Accounts
Receivable, Valuable Papers
Do you want coverage for Spoilage?
☐Yes ☐ No
Temperature change on perishable items
SALON/PERMANENT MAKEUP APPLICATION
Version: 10/2019 Page 3
Other Coverages: additional premium and application will apply
Do you provide any of the following? If so, please indication number of people performing
Decorative Tattooing/Body Piercing:
☐Yes ☐ No
Number of Technicians: ________________
Yoga/Personal Trainer:
☐Yes ☐ No
Number of Technicians: ________________
Laser/Intense Pulse Light:
☐Yes ☐ No
Number of Technicians: ________________
☐ Services not listed above: ______________________________________________________________________________________
______________________________________________________________________________________________________________
Do you want coverage for Non-Owned Or Hired Auto?
☐Yes ☐ No
If Yes, Separate Supplement Required
Do you want coverage for Sexual Abuse at $25K/$50K limits?
☐Yes ☐ No
Other limit requested: __________________
Do you want coverage for Cyber Protection at $50K limits?
☐Yes ☐ No
History: Note – ALL questions must be answered. Failure to disclose claims history could invalidate coverage
Do you Currently have Insurance coverage
☐Yes ☐ No
Insurer
Policy #
Liability Limits
Premium
Exp. Date
____________________________________________________________________________________________________________
If Claims Made, most Recent Retroactive Date: ______________________________________________________________________
List any Professional, General Liability or Property Claims history below, whether or not insured If None, Check Here ☐
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Do you have knowledge of an event, circumstance or occurrence (other than listed above) prior to the effective date of
the proposed policy, or are you aware that a claim may be brought as an result of said event, circumstance or
occurrence? If Yes, Describe Event
☐Yes ☐ No
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
ATTESTATION
I understand and agree this Application and any supplements attached hereto will be relied upon for issuance of any policy. I further understand and agree that failure to
provide a true and accurate response to the foregoing questions may, at the option of the company, result in the voiding of the insurance issued in reliance on this application
and/or denial of claims under any policy issued. I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to
engage in the activities of my business including authorization to every person or entity, public or private, to release all Lloyd’s of London participating syndicates, any
documents, records or other information bearing upon the foregoing. I understand and agree these investigations shall not be confined to information submitted in this
application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law. I understand this insurance is being provided
through a surplus lines company and the insurer may not be subject to all the insurance laws and rules in my state and the risk is not protected by the State Insurance
Insolvency Fund.
Furthermore, I understand that the policy applied for will apply only to CLAIMS FIRST MADE to the Company in writing within the period of coverage shown on the
certificate of insurance issued with the policy or certificate on the date the policy is canceled or terminated, whichever comes first or as otherwise provided by the policy. I
understand this insurance is being provided through a surplus lines company and the insurer is not subject to all the insurance laws and rules in my state and the risk is not
protected by the State Insurance Insolvency Fund.
THIS APPLICATION MUST BE SIGNED BY APPLICANT WITHIN 30 DAYS OF BINDING. SIGNING THIS FORM DOES NOT
BIND THE COMPANY TO COMPLETE THE INSURANCE. COVERAGE BECOMES EFFECTIVE WHEN ACCEPTED BY THE
INSURANCE COMPANY.
By signing below, I confirm on behalf of all technicians covered under this policy:
1. Technicians are licensed as necessary for all services being provided.
2. Technicians do not use any product that contains more than 2% formaldehyde.
3. I understand that no service or individual is covered unless listed and a premium paid.
4. That all technicians have been trained for the service they are performing or on the device they are using.
5. I understand that no coverage is provided under this policy for invasive or surgical procedures unless specifically listed
APPLICANT SIGNATURE TITLE
DATE SIGNED REQUESTED EFFECTIVE DATE LIABILITY LIMIT REQUESTED
One box below must be checked:
☐ I ELECT TO PURCHASE TERRORISM COVERAGE AT AN ADDITIONAL PREMIUM
☐ I DO NOT ELECT TO PURCHASE TERRORISM COVERAGE AT AN ADDITIONAL PREMIUM
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SALONPERMANENT MAKEUP APPLICATION (Special Risks)

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Completed 9 July 2021

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