Beauty shop/barber shop and day spa liability application



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BEAUTY SHOP/BARBER SHOP AND DAY SPA LIABILITY APPLICATION



In CA, DBA: Griffin Insurance Services, CA License #0G66558



800.562.8095 Phone . 425.453.8696 Fax

PO Box 3867. Bellevue, WA 98009



WWW.GOGUS.COM

Bellevue. Portland. Spokane.

Applicant’s Name       Agency Name      

Mailing Address       Agent      

      Address      

Location            



      E-mail      

Web site Address       Phone      



PROPOSED EFFECTIVE DATE: From       To       12:01 A.M., Standard Time at the address of the Applicant

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

PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”



Limits Of Liability And 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)

$     

Other Coverages, Restrictions and/or Endorsements:


$     

Deductible

$     

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 employed:      

Full-time:       Part-time (less than 15 hours per week):      

Aestheticians:       Masseuses:      

Full-time operators for ear piercing:      



5. Amount of gross sales: $     

6. Are all operators licensed?  Yes  No

7. Are records kept of patrons’ permanent waves and hair dyes?  Yes  No

8. Please state methods used in permanent hair waving (electric, cold wave, machineless, other):      

9. Does applicant manufacture, mix, blends or repackage products sold for use on or off
premises?
 Yes  No

If yes, explain:      

10. Number of:

Hot tubs/spas:       Hydro-massage beds:       Saunas:      

Swimming pools:       Tanning beds:       Toning beds:      

11. Are any operations performed away from the insured’s premises?  Yes  No

If yes, explain:      

12. Are any of the following exposures included in the applicant’s operation?

 Beauty Schools/Classes  Laser Hair Removal; receipts: $     

 Body Piercing  Makeovers/Facials

 Body Wraps  Manicures/Pedicures

 Botox or other Cosmetic Injections  Microdermabrasion; receipts: $     

 Chemical Peels; receipts: $       Nail Sculpting

 Chiropody  Permanent Cosmetics; receipts: $     

 Colon Hydrotherapy  Plastic Surgery

 Ear Piercing  Podiatry Detoxification

 Electrolysis  Teeth Whitening

 Face Lifting  Vein Treatments

 False Lashes  Wig Application

 Hair Implants  Waxing—hot/cold

13. Names of previous insurance carrier(s) for the past three years:      

Losses for the last three years: Indicate all claims or losses (regardless of fault and whether or not insured) or occur- rences that may give rise to claims:  See loss run attached      

14. Has any operator had a previous claim for alleged malpractice, error or mistake?  Yes  No

If yes, explain:      

15. 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:      

16. Does applicant have other business ventures for which coverage is not required?  Yes  No

If yes, explain and advise where insured:      



This application does not bind YOU nor US to complete the insurance, but it is agreed that the information 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 COLORADO APPLICANTS: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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 insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony 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 subject to fines and confinement in prison.

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 information is guilty of a felony.

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.

FRAUD WARNING (Applicable in Tennessee, Virginia and Washington): 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.

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 active owner, partner or executive officer)



PRODUCER’S SIGNATURE: DATE:      


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.




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