Salon & Spa Application

Transcription

1 3660 N Lake Shore Dr, Suite 2602, Chicago Salon & Spa Application General Information Named Insured: Entity Type: Primary Address, City, State, Zip: Mailing Address, City, State, Zip: Contact Person: Phone / Fax: Website: Year Business Established: Federal ID / Social Security Number: Description of Operations: General Questions Is applicant owned by or associated with any other entity? Does the applicant have 50% or more ownership in any other business? Are all operators licensed per state guidelines? Do all operations meet the requirements of the state s Health & Safety codes? Are any services provided that are not typical or customary to the beauty industry? Do you sell products that do not pertain to the salon/ spa industry? Do you rent to independent contractors/ booth lessees? If yes, do above carry liability insurance and name the applicant additional insured? Has the applicant, or any other person to be insured, had any liability applications or policies denied/ cancelled/ or not renewed in the past three years? Has the applicant, or any other person to be insured, had a license or certification investigated/ limited/ cancelled/ revoked/ surrendered to any licensing board or regulating agency? Is the applicant, or any other person to be insured, aware of any circumstances that could lead to a claim now or in the future? 1 Submit to Johnsonese Brokerage LLC, [email protected], Fax:

2 Insurance History Any insurance declined or cancelled in the past 3 years? If yes provide details: Any losses in the past 3 years? If yes, provide details below. Policy / Line Date of Loss Description of Loss Amount of Loss Any prior insurance coverage? If yes, provide details below. Policy Type Carrier Policy # Expiration Date Premium Business Details Annual Revenues $: Percentage from Services: Percentage from Product Sales: Business Services Do you provide the following services?: Skin peels Electrolysis Microdermabrasion Tanning Nutritional or weight control counseling Permanent makeup Removal of warts/ moles / growths Body piercing (other than ear and nose) Chiropody / Podiatry Hair transplanting/ implanting Saunas or steam baths Laser treatments Eyelash or eyebrow tinting/ coloring Face lifting 2 Submit to Johnsonese Brokerage LLC, [email protected], Fax:

3 Personnel Type Cosmetologist No. Full-Time Employees No. Part-Time Employees No. of Full-Time Contractors/ Lessees No. of Part-Time Contractors/ Lessees Barber Manicurist Massage Therapist Assistant Front Desk Other Location Information Do you own or lease your space? Building construction (Frame, Joisted Masonry, Non-Combustible, Masonry Non-Combustible, Modified Fire Resistive, Fire Resistive) Area Occupied (Square Feet) Sprinklered? Yes/ No Burglar alarm? Yes/ No If yes, central station or local? If central station, alarm monitoring company Year Built If older than 15 years, year of most recent updates: Electrical Plumbing Roofing HVAC Any Additional Insureds required? Yes/ No If yes, provided name, address, relationship: 3 Submit to Johnsonese Brokerage LLC, [email protected], Fax:

4 Coverages (Note that not all coverages listed are available for all applications or in all states.) Effective / / General Liability Occurrence Aggregate Automobile Owned Auto Liability Hired & Non-Owned Auto Liability Workers Compensation* Limit of Employer s Liability All States Endorsement (Include or Exclude) *If you requested workers comp coverage, please complete the following: Annual Compensation (pay $) Property Building Tenant s Improvements Business Personal Property Tenant s Glass Signage Personal Property Others Electronic Data Processing Other: Excess Liability Occurrence Limit Aggregate Limit Note: Availability of coverage will depend on individual risk characteristics and the state in which the insured is located. 4 Submit to Johnsonese Brokerage LLC, [email protected], Fax:

5 THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER, BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS FOR THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT MAY BE ATTACHED TO AND MADE PART OF THE POLICY. THE APPLICANT REPRESENTS THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME THE POLICY IS ISSUED, THE APPLICANT WILL PROVIDE WRITTEN NOTIFICATION OF SUCH CHANGES. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance 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 the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied. Applicant warrants that all operations meet relevant state health and safety regulations. Applicant Signature: Date: Applicant Name Printed: 5 Submit to Johnsonese Brokerage LLC, [email protected], Fax: