Applicant’s Name:

First Last

Mailing Address:

Location Address:

E-mail:

Phone No:

PROPOSED EFFECTIVE DATE:

Form To

Name Of Business (D/B/A):

Website:

Business is (check all that apply):

Describe (If Other)

Total gross sales: $

Percentage for services rendered:

%

Percentage for products:

%

Total number of operators/technicians (including owners, employees, and independent contractors):

Full-time hair:

Part-time hair (less than twenty [20] hours per week):

Estheticians:

Nail Technicians

Masseuses/Masseurs:

Tattoo Artists:

Body Branding/Modification Artists:

Body and Ear-Piercing Artists:

Permanent Makeup Artists:

Other (Describe):

Permanent Makeup Artists:

Premises exposures:

Low-Level Light Therapy Booths:

Beauty/Barber Shop chairs:

Tanning spray-on booths:

Float Tanks:

Tanning booths:

Saunas:

Hot tubs/spas:

Hydromassage beds:

Swimming Pools:

Toning beds:

Tanning beds:

Other (describe):

Are all operators licensed?

Yes

No

Services Rendered. Please indicate the percentage of gross sales for each service provided, totaling 100%:

Anal or genital whitening or steaming

Percentage of Gross Sales (%)

Acne scar treatment

Percentage of Gross Sales (%)

Aromatherapy

Percentage of Gross Sales (%)

Acupuncture

Percentage of Gross Sales (%)

Body masks or body wraps:

Percentage of Gross Sales (%)

Body branding—Method:

Percentage of Gross Sales (%)

Chemical peel—light

Percentage of Gross Sales (%)

Body scrubs:

Percentage of Gross Sales (%)

Chemical peels—medium and deep

Percentage of Gross Sales (%)

Chiropody or podiatry

Percentage of Gross Sales (%)

Cortisone or steroid treatments

Percentage of Gross Sales (%)

Cosmetic injections (e.g. Botox, Juvederm, or similar)

Percentage of Gross Sales (%)

Dental spas (e.g. permanent jewels, teeth modification)

Percentage of Gross Sales (%)

Diet, nutritional or weight loss consultation

Percentage of Gross Sales (%)

Ear candling/coning

Percentage of Gross Sales (%)

Dermaplaning

Percentage of Gross Sales (%)

Electrolysis hair removal

Percentage of Gross Sales (%)

Ear piercing

Percentage of Gross Sales (%)

Enzyme baths

Percentage of Gross Sales (%)

Eyelash/Eyebrow—tinting

Percentage of Gross Sales (%)

Eyelash/Eyebrow—shaping, conditioning, and serums

Percentage of Gross Sales (%)

Facials, including exfoliation

Percentage of Gross Sales (%)

Eyelash—extensions and fills

Percentage of Gross Sales (%)

Fat reduction or body contouring by advanced technologies:

Percentage of Gross Sales (%)

Hair extensions

Percentage of Gross Sales (%)

Fibroblasting

Percentage of Gross Sales (%)

Hair coloring or other chemical treatments

Percentage of Gross Sales (%)

Haircut and styling

Percentage of Gross Sales (%)

Henna tattoo—natural

Percentage of Gross Sales (%)

Head lice removal

Percentage of Gross Sales (%)

Henna tattoo—synthetic and/or black

Percentage of Gross Sales (%)

Ice bath—other than medical

Percentage of Gross Sales (%)

Hydro massage beds

Percentage of Gross Sales (%)

Hyperbaric oxygen treatments (HBOT)

Percentage of Gross Sales (%)

Laser hair removal

Percentage of Gross Sales (%)

Infrared services

Percentage of Gross Sales (%)

Intense pulsed light (IPL) treatments

Percentage of Gross Sales (%)

Low-level light therapy (LLLT)

Percentage of Gross Sales (%)

Massage

Percentage of Gross Sales (%)

Massage—prenatal

Percentage of Gross Sales (%)

Medical spas/med spa

Percentage of Gross Sales (%)

Microdermabrasion or Microplanning

Percentage of Gross Sales (%)

Mesotherapy treatment

Percentage of Gross Sales (%)

Makeup application—for special occasions

Percentage of Gross Sales (%)

Nail services (e.g. manicures, pedicures)

Percentage of Gross Sales (%)

Paraffin wax treatment

Percentage of Gross Sales (%)

Permanent makeup including microblading

Percentage of Gross Sales (%)

Piercing—ear

Percentage of Gross Sales (%)

Piercing—body—Describe:

Percentage of Gross Sales (%)

Scalp treatments

Percentage of Gross Sales (%)

Podiatry detoxification

Percentage of Gross Sales (%)

Shaving

Percentage of Gross Sales (%)

Scar or stretchmark camouflage

Percentage of Gross Sales (%)

Subdermal Implants

Percentage of Gross Sales (%)

Sun tanning salons

Percentage of Gross Sales (%)

Tanning beds/booths

Percentage of Gross Sales (%)

Toning beds

Percentage of Gross Sales (%)

Tattoo

Percentage of Gross Sales (%)

Tattoo, port wine or birthmark removal

Percentage of Gross Sales (%)

Tissue extraction (e.g. dermal punch)

Percentage of Gross Sales (%)

Threading—eyebrow or face

Percentage of Gross Sales (%)

Vein treatments

Percentage of Gross Sales (%)

Waxing—hair removal

Percentage of Gross Sales (%)

Other—Describe:

Prior Policy

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Upload Your Current Insurance Policy or Related Documents

Drop files here or

Max. file size: 20 MB, Max. files: 10.

Total number of operators/technicians (including owners, employees, and independent contractors):

Premises exposures:

Services Rendered. Please indicate the percentage of gross sales for each service provided, totaling 100%:

For Tanning Beds, Booths and Spray-on Booths:

Prior Policy

Recents Articles

The Importance of Long-Term Care Insurance in Future Planning

Why Health Insurance is Essential for Every Business Owner and Their Employees

April Insurance Agency

Get A Quote

Helpful Links

For Clients

Beauty Barber Insurance Quote

Total number of operators/technicians (including owners, employees, and independent contractors):

Premises exposures:

Services Rendered. Please indicate the percentage of gross sales for each service provided, totaling 100%:

For Tanning Beds, Booths and Spray-on Booths:

Prior Policy

Recents Articles

The Importance of Long-Term Care Insurance in Future Planning

Why Health Insurance is Essential for Every Business Owner and Their Employees

April Insurance Agency

Get A Quote

Helpful Links

For Clients