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Beauty ShopBarber Shop and Day Spa Liability Application

By Vivian Pierce,2014-06-28 08:40
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Beauty ShopBarber Shop and Day Spa Liability Application ...

     Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company

    Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive

     Columbus, Ohio 43215 Scottsdale, Arizona 85258

    Adm. Office: 8877 North Gainey Center Drive

     Scottsdale, Arizona 85258

     Scottsdale Indemnity Company

    Home Office: One Nationwide Plaza

     Columbus, Ohio 43215

    Adm. Office: 8877 North Gainey Center Drive

     Scottsdale, Arizona 85258

    1-800-423-7675 Fax (480) 483-6752

    www.scottsdaleins.com

    Beauty Shop/Barber Shop and Day Spa Liability Application

    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 BBS-APP-1 (1-09) Page 1 of 3

    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 Waxinghot/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 applicant have other business ventures for which coverage is not required? ...................... Yes No

    If yes, explain and advise where insured: BBS-APP-1 (1-09) Page 2 of 3

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 in-

    surance or statement of claim containing any materially false information or conceals for the purpose of misleading, in-

    formation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such

    person to criminal and civil penalties.

    FRAUD WARNING 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 appli-

    cation containing any false, incomplete, or misleading information is guilty of a felony in the third degree.

    FRAUD WARNING 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.

    FRAUD WARNING 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 kno-

    wingly 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.

    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. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

    Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-

    surance or statement of claim containing any materially false information, or conceals for the purpose of misleading, in-

    formation 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:

     IMPORTANT NOTICE

    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.

    BBS-APP-1 (1-09) Page 3 of 3

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