• Personal Appearance Insurance Questionnaire

  • Applicant is:

  • General Information

    (Salon, Barber Shop, Hair Stylist, Esthetician, Nail Technician, Manicurist, Massage Therapist, Cosmetologist, Tanning Salon, Beauty School, Barber School, Cosmetology School, Booth Rental, Independent Contractor)

  • 4. Is your operation licensed?
  • 6. Do you own any buildings with more than 2 apartments at any one covered location?
  • 7. In the last 3 years, has the operation had any losses or claims?
  • 8. In the past 3 years, has any prior policy been cancelled, declined or non-renewed (except MO)
  • 9. Has the operation ever had any personal appearance care license/certification suspended or revoked?
  • 10. Are you currently insured?
  • 11. Do you have any prior claims?
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  • LIABILITY

  • 1. Liability limit desired:
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  • 3. Would you like to include Employee Benefits Coverage (Liability for Error or Omission of Employee Benefit Program)?
  • 4. Would you like to include Employment Practices Liability (Sexual Harassment, Wrongful Dismissal, EEOC)?
  • 4a. Limit
  • 5. Are additional insureds needed?
  • 6. Do you offer services through independent personal appearance contractors?
  • 6a. If yes, are certificates of insurance provided with limits equal to or greater than applicant?
  • 6b. Do you require contractors to name you as additional insured on their policy?
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  • Please answer all of the following questions:

  • 1. Does the applicant perform any non-personal appearance care services or operations other than sales/service of beauty related products?
  • 2. Does the applicant perform body wraps?
  • 3. Does the applicant perform chiropody or podiatry? (if yes, coverage does not apply.)
  • 4. Does the applicant perform permanent cosmetic application? (if yes, coverage does not apply.)
  • 5. Does the applicant perform any types of laser treatments? (if yes, coverage does not apply.)
  • 6. Does the applicant perform wart, mole, or other growth removal? (if yes, coverage does not apply.)
  • 7. Does the applicant operate a home salon providing personal appearance care services in the residence?
  • 8. Do you manufacture any of your own products?
  • 8a. If yes, is it consumed/used?
  • 9. Do you sell others’ products?

  • TANNING SALONS

  • 1. Does the applicant provide any tanning services? (If yes, please answer the questions below.)
  • 1b. Are all customers given information about the types of rays and the potential sensitivity?
  • 1c. Are records kept on each tanning customer for each visit and exposure time?
  • 1d. Are eye protection goggles required for all users?
  • 1e. Does an employee sanitize beds after every use?
  • 1f. Does the customer sign a waiver of liability before using tanning services? (If yes, provide a copy of the waiver.)
  • 1g. Do the doors and walls extend from the floor to the ceiling?
  • 1h. Is the building equipped with surge protection on the electrical panels?

  • MASSAGE THERAPISTS

  • 1. Does the applicant provide any massage therapy services? (If yes, please answer the questions below.)
  • 1a. Has any massage therapist ever been sued for malpractice?
  • 1b. Do the clients complete an application before the first massage? (If yes, please provide a copy of the application.)

  • ELECTROLOSIS

  • 1. Does the applicant provide any electrolosis services? (If yes, please answer the questions below.)
  • 1c. Are reactions to electrological procedures recorded?

  • OTHER SERVICES / OPERATIONS

  • 1. Does the applicant perform any other services or operations?

  • PROPERTY INSURANCE

  • 1. Do you own any buildings?
  • 1a. If yes, do you lease any part of any of the building(s) at this location to others? (If yes, a copy of the certificate of insurance for the leased area is required.)
  • 2. Do you need Building and/or Content Coverage?
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  • 3. Do you need Equipment Coverage?
  • 3a. If yes, total value to insure for?
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  • 4. Any additional interests?

  • OPTIONAL PROPERTY COVERAGES

  • 1. Do you need additional Computer Coverage ($25,000 included)?
  • 2. Do you need Condominium Unit – Owner Coverage?
  • 3. Do you need Earthquake Coverage – Building?
  • 4. Do you need Earthquake Coverage – Personal Property?
  • 5. Do you need Legal Liability?
  • 6. Do you need additional Money & Securities Coverage?
  • 7. Do you need additional Outdoor Sign Coverage ($10,000 included)?
  • 8. Do you need additional Employee Dishonesty Coverage ($5,000 included)?
  • 8b. Limit:

  • COMMERCIAL AUTOMOBILE INSURANCE

  • 1. Does the business title any automobiles or other operating vehicles in the business name?
  • 2. Is insurance coverage needed for owned automobiles?
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  • 3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?
  • 3b. Do you verify they have liability coverage?

  • COMMERCIAL UMBRELLA

  • 1. Do you need a Commercial Umbrella?

  • WORKERS' COMPENSATION INSURANCE

  • 1. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)
  • 2. Is there a written return to work program in place? If yes, please attach a copy.

  • STOP GAP LIABILITY (Ohio Only) *Note: A signed Ohio Fraud Statement is required for applications.

  • 3. Is Stop Gap Liability Requested? (Ohio Only)
  • 3a. If yes, please choose desired limits:

  • SIGNATURE

  • I have read the above questions and I hereby declare to the best of my knowledge and belief that all of the foregoing statements are true and that these statements are offered as an inducement to the company to issue the policy for which I am applying.
    NOTICE: PLEASE READ BEFORE SIGNING!
    In order to underwrite the insurance applied for above, an investigation consumer report may be requested and made, including information as to the character of the applicant for insurance and the persons to be insured under the policy applied for, their general reputations, business characteristics and credit standing. You are advised that you may make a request within a reasonable time after receipt of this Notice for a disclosure by West Bend Mutual Insurance Company of the nature
    and scope of the investigation requested.
    Fraud Warning
    Kentucky: Any person who knowingly and with intent to defraud any insurance company or other 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.
    Ohio: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
    All Other States: Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, may be guilty of insurance fraud in violation of state law. Penalties may include
    imprisonment, fines, or denial of insurance benefits.

  • Questions? 877-244-9090
    Kevin Morency |  kmorency@morencyinsurance.com 

    Morency & Associates Inc.
    141 New Shackle Island Rd, Hendersonville, TN 37075
    Fax: 615-452-6580

    https://spasaloninsurance.com/

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