Fillable Tattoo & Body Piercing Insurance Application (All Risks, Ltd)

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Tattoo & Body Piercing Insurance Application (All Risks, Ltd)

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National Specialty Programs
Toll-
Free: 800-366- 5810 • Fax: 410-828-8179
Contact us: programs@ryansg.com
Tattoo & Body Piercing Insurance Application 011121 Page 1 of 6
RSGprograms.com
Tattoo & Body Piercing Insurance Application
1. First Named Insured: _________________________________________________________________________________
2. Type of Entity: Individual Partnership Corporation Other: __________________
3. Other insureds: _______________________________________________________________________________________
Relationship to the First Named Insured: ___________________________________________________________________
4. Mailing Address: ______________________________________________________________________________________
Street City County State Zip Code
5. Contact Name: _______________________________________________________________________________________
Phone Number: __________________________________________ Fax Number: _______________________________
Insured Email Address: _____________________________________ Website Address: ___________________________
Current Expiration Date: _______________ Bind Date Requested: _______________ Need Quote By: ______________
6. Property Location Information
Loc.
No.
Street Address
City
County
State
Zip Code
1
2
3
*If there are more than 3 locations, please add an additional page to the application with the list of those addresses.
7. Have there been any gaps in coverage in the past three years? Yes No
If yes, please explain: ___________________________________________________________________________
8. Have there been any losses in the last three years? Yes No
9. General Liability
Limits
General Aggregate
Products-Completed Operations Aggregate
Personal and Advertising Injury Limit
Each Occurrence Limit
Damage to Premises Rented to You
Medical Expense Limit
10. Hired and Non-Owned Liability: Exclude Include
11. Employee Benefits Liability: Exclude Include
12. Disease Sublimit ($25,000/$25,000): Exclude Include
13. Disease Sublimit ($50,000/$50,000): Exclude Include
14. Disease Sublimit ($100,000/$100,000): Exclude Include
15. How many off premises exhibitions do you per year? ________________________
16. Property (A schedule of buildings may be attached in lieu of completing the schedule below)
Loc.
No.
Bldg.
No.
Coverage
Limit of
Insurance
ACV, RC or
Agreed
Co-Insurance
Constr.
Class
PC
80%
80%
80%
80%
*This section MUST be fully completed if they require any property coverage, including BPP.
Deductible: $1,000 $2,500 $5,000 $10,000 $25,000
Tattoo & Body Piercing Insurance Application 011121 Page 2 of 6
RSGprograms.com
17. Property Coverage Extensions
The following coverage extensions are included without additional charge at the limits indicated below. Higher limits may
be available for an additional charge.
Coverage
Limit Provided
Coverage
Limit Provided
Accounts Receivable
$10,000 _____________
Money & Securities – Inside
$10,000 _____________
Back Up of Sewers
$10,000 _____________
Money & Securities – Outside
$10,000 _____________
Business Computer Media/Data
$10,000 _____________
Outdoor Property
$10,000 _____________
Employee Dishonesty
$15,000 _____________
Outdoor Signs
$2,500 _____________
Extra Expense
$1,000 _____________
Personal Effects
$10,000 _____________
Fine Arts
$25,000 _____________
Property Off Premises
$10,000 _____________
FD Service Charge
$2,000 _____________
Valuable Papers
$10,000 _____________
BUILDING UNDERWRITING INFORMATION
18. Indicate year of updates – attach a separate sheet if necessary
Bldg.
No.
Year
built
Roof
HVAC
Plumbing
Electrical
No. of
Floors
Sprinklered
Fire Alarm
(Indicate L, P, or CS)
1
Yes No
L P CS
2
Yes No
L P CS
3
Yes No
L P CS
*This section MUST be fully completed if they require any property coverage, including BPP.
19. Distance to nearest fire hydrant? ___________________ Distance to nearest Fire Department? __________________
20. If you own your building, do you lease space to others?
If yes, to whom: __________________________ Square feet leased: __________________________
21. Do you have 24-hour video surveillance in use on the premises? Yes No
If yes, how many cameras: __________________ Do they have night vision? Yes No
22. Do you have a central control station burglar alarm? Yes No
23. Have you or anyone with a financial interest in the property been convicted of arson, fraud, or other
crime related to loss of property owned now or during the past five years? Yes No
GENERAL BUSINESS AND STAFF INFORMATION
24. Operation Profile
Total Sales
$
Years in Business
__________ Years
Jewelry Sales
$
Hours Open
_________ to _________
Payroll
$
# of Years Records Retained
__________ Years
25. Staffing and Revenue
Personnel
Number of
Number of
Tattoo Artists
Number of
Piercing Artists
Full-Time Artists
Part-Time Artists
Permanent Make-Up Artist – Full-Time
N/A
N/A
Permanent Make-Up Artist – Part-Time
N/A
N/A
Apprentice (Not included above)
TOTAL
26. Are Independent Contractors included in list of Named Artists on question #25? Yes No
If no, please provide copies of Additional Insured Certificates naming other insured(s) on
the policy. *Independent Contractors are excluded if not added as a Named Artist
Tattoo & Body Piercing Insurance Application 011121 Page 3 of 6
RSGprograms.com
27. Staff (needed to complete Named Artist endorsement):
Name
Length of Employment
Years of Experience
*If there are more than 10 artists, please add an additional page to the application with the list of additional artists.
28. Are you a member of a State or National Tattoo or Body Piercing Association? Yes No
If yes, which association: _________________________________________________________
29. Are you licensed by the state or city and meet all city or state regulations? Yes No
30. Do you perform body piercing or tattooing on minors? Yes No
If yes, what is the minimum age for: Body Piercing: ___________________ Tattooing: __________________
Do you require parental consent with ID? Yes No
Please provide areas of body piercing and/or tattoos on minors: _________________________________
What is the approximate percentage of business from minors? ____________%
31. Do you validate the age of all clients? Yes No
32. Do you require waivers on all of your clients and maintain copies on file? Yes No
33. Do you obtain a medical history on every client? Yes No
34. Do you perform tattoo or body piercing work away from your studio? Yes No
If yes, please describe: __________________________________________________________________________
35. Do you employ apprentices? If yes, please attach a detailed description of the training program. Yes No
36. Do you purchase ink supplies from overseas suppliers or distributors? Yes No
37. Are pre-employment background checks performed on all employees? Yes No
38. Is there a weapon kept on premises? Yes No
Assault and Battery Exclusion applicable if weapon on premises
TATTOO, PIERCING AND OTHER SERVICES INFORMATION
39. Do you perform body piercings? Yes No
Please indicate which body parts piercings are performed on:
Ears Lips Tongue Navel Nipples Genitals
Eyebrows Nose Hand Axilla Feet Surface Piercings
Dermal Anchors Eyes Other: ______________________________
40. Do you perform any services as part of a medical procedure? Yes No
41. Do you do any “Areola Pigmentation”? Yes No
If yes, please complete and submit the Consent Form for Areola Pigmentation.
42. Do you do any tattooing of the eyeball? Yes No
43. Do you offer any type of branding or scarification services? Yes No
44. Do you offer micro-needling services? Yes No
45. Do you have any other operations beside Tattooing and Body Piercing? Yes No
If yes, please describe: _________________________________________________________________________
46. Do you perform any Tattoo Removals? Yes No
Tattoo & Body Piercing Insurance Application 011121 Page 4 of 6
RSGprograms.com
SAFETY AND STERILIZATION INFORMATION
47. Do you have written sterilization, sanitation and safety standards? Yes No
48. Do you use new needles for each new client? Yes No
49. Do you use new gloves for each new client? Yes No
50. Do you have Blood Borne Pathogen Training? Yes No
51. Do you have an Autoclave System? Yes No
52. Are you contracted with a bio waste disposal firm? Yes No
53. Are sharp waste containers used in your studio? Yes No
If yes, how disposed: ___________________________________________________________________________
54. Has anyone ever claimed to have contracted HIV, Herpes, or AIDS from you? Yes No
55. Please describe the sterilization methods you employ: _______________________________________________________
___________________________________________________________________________________________________
56. Do you provide clients with materials on aftercare of tattoos and/or body piercings? Yes No
57. Do you videotape procedures for documentation procedures? Yes No
58. Do you have a policy for handling intoxicated persons? Yes No
If no, do you ever allow intoxicated persons to have tattoos or piercings? Yes No
59. Do you have a private piercing room? Yes No
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT
Interest: Additional Insured Loss Payee Mortgagee
Lienholder Other: ___________________
Name and Address: ___________________________________________________________________________________
Certificate Required
Interest in Item Number: Location #: ________ Building #: ________
Interest: Additional Insured Loss Payee Mortgagee
Lienholder Other: ___________________
Name and Address: ___________________________________________________________________________________
Certificate Required
Interest in Item Number: Location #: ________ Building #: ________
If the additional insured information is the same as on the current policy, please write “same.” If there are any changes or additions
to the additional insured information, please list them: _______________________________________________________________
____________________________________________________________________________________________________________
I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. Any person who, with the intent to
defraud or knowing that he or she is facilitating a fraud against an Insurer, submits an application or files a claim containing false or
deceptive statement may be guilty of insurance fraud and subject to fines and/or imprisonment.
_______________________________________________ ________________________________ _____________________
Signature of Applicant Title Date
_______________________________________________ _________________________________
Signature of Producing Agent Date
____________________________________________________________________________________
Agent Name and Address
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Tattoo & Body Piercing Insurance Application 011121 Page 5 of 6
RSGprograms.com
NOTICE TO APPLICANT - PLEASE CAREFULLY READ THE FOLLOWING
ARIZONA FRAUD STATEMENT - For your protection Arizona law requires the following statement to appear on this form. Any person
who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
ARKANSAS FRAUD STATEMENT - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly pre-presents false information in an application for insurance is guilty of a crime and may be subject to fines and confine-
confinement in prison.
CALIFORNIA FRAUD STATEMENT - For your protection, California law requires that you be made aware of the following: Any person
who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
COLORADO FRAUD STATEMENT - It is unlawful to knowingly provide false, incomplete, or misleading facts or information 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 de-frauding 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.
DISTRICT OF COLUMBIA FRAUD STATEMENT - WARNING: 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.
IDAHO FRAUD STATEMENT- Any person who knowingly, and with intent to defraud or deceive any insurance company, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
INDIANA FRAUD STATEMENT - Any person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading information commits a felony.
LOUISIANA FRAUD STATEMENT - 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.
MAINE FRAUD STATEMENT - 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.
MINNESOTA FRAUD STATEMENT - Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
NEW HAMPSHIRE FRAUD STATEMENT - Any person who, with a purpose to injure, defraud or deceive any insurance company, files
a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for
insurance fraud, as provided in RSA 638:20.
NEW JERSEY FRAUD STATEMENT – APPLICATION - Any person who includes any false or misleading information on an application
for an insurance policy is subject to criminal and civil penalties.
Tattoo & Body Piercing Insurance Application 011121 Page 6 of 6
RSGprograms.com
NEW MEXICO FRAUD STATEMENT - 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 civil fines and
criminal penalties.
OHIO FRAUD STATEMENT - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA FRAUD STATEMENT - WARNING - 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 information is guilty of a
felony.
OREGON FRAUD STATEMENT - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines
and confinement in prison.
PENNSYLVANIA FRAUD STATEMENT - 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.
VIRGINIA, TENNESSEE FRAUD STATEMENT - It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
FRAUD STATEMENT (All other states) - Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly pre-presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confine-confinement in prison.
RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a
subsidiary of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the
public. Some products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC
(License # 0G97516). ©2021 Ryan Specialty Group, LLC
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Completed 20 January 2021

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