Body Piercing & Tattoo Liability Insurance Application

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Presentation Description

APP offers PL & GL insurance coverage for Allied Healthcare professionals & business entities through AM Best “A” rated Insurance Companies. Here is the Application for Body Piercing & Tattoo Liability Insurance.

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BODY PIERCING TATTOO LIABILITY INSURANCE APPLICATION 1.1 Your Name: Phone Business Names: Email Address: Website:____________________________________ Mailing Address: Business Address 1: Business Address 2: 1.2 Your Business structure: Corporation LLC Employee Sole Proprietorship Partnership 1.3 Working as: Tattoo and/or Piercing Business ___ Ind. Operator ___ Number locs:____Other describe 1.4 Do you operate a retail sales business grossing over 10000 Do you have other insurance for it 1.5 Are you in compliance with all city county state ordinances and work in a business shop 1.6 How long in the business of body piercing tattooing 1.7 Have you had formal instruction in body piercing Yes No Tattooing Yes No PART II. GENERAL INFORMATION ON YOUR PROFESSION 2.1 Do you use a release/client info. form on everyone If yes attach a copy for all services. Yes No 2.2 Do you use an aftercare form on everyone If yes attach a copy. Yes No 2.3 Do you ever tattoo minors 2.4 Do you ever pierce minors If yes under what circumstances 2.5 How do you sterilize equipment and materials prior to use 2.6 Do you have hot and cold running water on site Yes No 2.7 Do you wear a new pair of gloves with each procedure Yes No PART IIIa. EQUIPMENT AND PROCEDURES - PIERCING 3.1 How do you sterilize jewelry prior to insertion 3.2 Do you use sterile needles with each individual piercing Yes No 3.3 Is all jewelry you use from US manufacturers or from Cold Steel/Wild Cat in UK Yes No What is the jewelry you use made of 3.4 How are hard surfaces disinfected 3.5 How is the body area prepared before piercing PART IIIb. EQUIPMENT AND PROCEDURES - TATTOOING 3.6 Are all pigments from US Manufacturers Yes No 3.7 Do you ever re-use needles Yes No

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PART IV. HISTORY NOTE: All questions must be answered. Failure to disclose claims history could invalidate coverage. 4.1 Do you currently have insurance coverage Yes No If yes indicate the following: Insurer Policy Liability Limits Premium Exp. Date If claims made most recent retroactive date: 4.2 List liability claims history arising from any body piercing tattoo permanent makeup or other professional activity whether or not insured: If none state so_____________ YR/Claim Nature of injuries Equip. Involved Details if Pending Amt. if settled 4.3 Do you have knowledge of an event circumstance or occurrence other than listed in 4.2 above prior to the effective date of the proposed policy or are you aware that a claim may be brought as a result of said event circumstance or occurrence Yes No. If yes describe details of the event: 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. Furthermore I understand that the policy applied for will apply only to CLAIMS FIRST MADE AND REPORTED 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 APPLICANT SIGNATURE TITLE DATE SIGNED REQUESTED EFFECTIVE DATE LIABILITY LIMIT REQUESTED Can we email you your policy usually within 2-3 weeks Yes No _____________________________________ _____ One box below must be checked: I ELECT TO PURCHASE TERRORISM COVERAGE AT A 10 ADDITIONAL PREMIUM 1 DO NOT ELECT TO PURCHASE TERRORISM COVERAGE AT A 10 ADDITIONAL PREMIUM ADDITIONAL INSURED: 30 Certificate Holder Landlord or Lessor If necessary add other names on separate paper. NAME: ADDRESS: Relationship to your business Landlord lienholder:

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ARTISTS/PIERCERS TO BE INSURED To be used for more than one artist piercer and/or location A. Name of Shop: B. Owners of shop: C. Artists/Piercers to list on policy: List years of experience next to services you would like covered Yrs. Yrs. 1. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 2. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 3. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 4. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 5. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 6. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 7. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 8. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 9. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer 10. Tattoo _______ Piercing ______ Anchor / Surface Master Piercer If piercing to be covered I elect one of the following options: I would like to purchase Minor Piercing Coverage: for ear cartilage nose navel tongue midline only lips and eyebrow on minors 13 and over with written parental consent. Available if legal in your state I do not want Minor Piercing coverage at this time If Tattooing to be covered I elect one of the following options: I would like to purchase Minor Tattoo Coverage: for 16 17 years with written parental consent. Available if legal in your state I do not want Minor Tattoo coverage at this time D. ADDRESS OF LOCATIONS TO BE INSURED indicated business name if different from that listed above 1. 2. 3. I the owner of the above indicated business hereby warrant and confirm each tattooer and/or piercer listed above for coverage while operating under my business will follow the guidelines and procedures that I indicate I follow on the insurance application including use of proper sterilization on all equipment no reuse of needles registration of clients and providing each client instructions on how to care for their tattoo and/or piercing. Signed: Date:

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ACCEPTABLE PIERCINGS  PROCEDURES   1 or More Years Experience    EARS Lobes Inner Cartilage  Outer Cartilage   Lobe   Helix Upper Helix Forward                  Helix Conch Snug        Industrial     Rook Daith     Transverse or Vertical Lobe    NOSE  NOSE AREA EYE AREA   Nostril High Nostril Septum    Bridge     Monroe     Horizontal Eyebrow    BODY   Nipple   Navel      LIPS  MOUTH   Philtrum     Labret Vertical Labret     Jestrum   Vertical Philtrum     Tongue midline only away                  from main veins      MALE GENITAL   Frenum or Frenulum  Lorum   Foreskin   Scrotal Piercing/Halfada   Prince Albert Dolphin   Guiche      FEMALE GENITAL   Inner Outer Labia   Vertical Horizontal  Hood    Fourchette    STRETCHING Ear Lobes Only       OPTIONAL COVERAGE – 2 YEARS EXPERIENCE – SURFACE PIERCING/DERMAL ANCHORS   Surface Bars – Nape sideburn eyebrow‐horizontal anti‐eyebrow third eye chest/sternum                          lower navel‐horizontal hips Christina   Anchors – Nape neck forehead third eye eyebrow cheekbone sideburn chest  stomach                  hips pubic area faux Christina forearm back    ACCEPTABLE PIERCINGS –MASTER PIERCER  3 or More Years Experience    Master Piercer coverage includes all of the above Piercings plus Surface Piercing/Dermal Anchoring plus  “O” or “Chamfer” needles ‐‐ and the following additional Piercings:  NOSE NOSE AREA  EYE AREA   Anti‐brow    Vertical bridge   LIPS/MOUTH/FACE   Tongue Webbing/Tongue Frenulum   Smiley/Scrumper    Dimple   Lowbret    MALE GENITAL   Ampallang    Apadravya    Dydoe     FEMALE GENITAL   Triangle   Christina     UNDER 1 YEAR EXPERIENCE APPRENTICE:   Eyebrow Earlobe Outer Rim Ear Cartilage Lower Lip‐Sides and Center Nostrils‐Thin or Hyaline                   Cartilage Only Navel Nipples    MINOR PIERCING  Ear nose navel lips tongue midline only  eyebrow piercings on minors age 13 years or over with  written  parental  consent  ear lobes children age 3 months and older ‐ if state law specifies an older  age you must follow state law     MINOR TATTOOING  In states where legal age 16 or over with written parental consent  Additional Premium Applies

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