Spa & Salon Insurance Questionnaire

	Number
2a. Beauty/Barber/Manicurist/Aesthetician (Full-Time Operators)
2b. Beauty/Barber/Manicurist/Aesthetician (Part-Time Operators - 29 hours or less per week)
2c. Electrologist (Full-Time Operators)
2d. Electrologist (Part-Time Operators – 29 hours or less per week)
2e. Hot tub (s)
2f. Sauna (s)
2g. Steam Rooms (s)
2h. Instructors (Beauty, Barber, Massage School)
2i. Massage Therapists (Full-Time Operators)
2j. Massage Therapists (Part-Time Operators – 29 hours or less per week)
2k. Aqua Massage Beds
2l. Sun Tan Beds (bulb-style beds)
2m. Air-Brush or Spray-On Tanning Beds

PROPERTY INSURANCE

1. Do you own any buildings?

YesNo

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.)

YesNo

1b. If yes, what is the total square footage leased to others?

1c. Total number of apartments at this location? (A copy of the lease agreement and HO-4 is required if coverage is bound. )

2. Do you need Building and/or Content Coverage?

YesNo

2a. If yes, please complete chart below or provide a separate property schedule with the following information:

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

3. Do you need Equipment Coverage?

YesNo

3a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

3b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

3c. Please list other equipment below

4. Any additional interests?

YesNo

4a. If yes, please provide name and address of Mortgagee(s) and/or Loss Payee(s)

OPTIONAL PROPERTY COVERAGES

1. Do you need additional Computer Coverage ($25,000 included)?

YesNo

1a. If yes, requested amount?

2. Do you need Condominium Unit – Owner Coverage?

YesNo

3. Do you need Earthquake Coverage – Building?

YesNo

4. Do you need Earthquake Coverage – Personal Property?

YesNo

5. Do you need Legal Liability?

YesNo

5a. Building Limit ($)

6. Do you need additional Money & Securities Coverage?

YesNo

6a. Inside Premises ($15,000 included)

Excess Inside Limit Requested ($)

6b. Outside Premises ($7,000 included)

Excess Outside Limit Requested ($)

7. Do you need additional Outdoor Sign Coverage ($10,000 included)?

YesNo

7a. If yes, requested amount ($)

8. Do you need additional Employee Dishonesty Coverage ($5,000 included)?

YesNo

8a. Number of Employees

8b. Limit:

$10,000$25,000For higher limits, contact Kevin Morency

COMMERCIAL AUTOMOBILE INSURANCE

1. Does the business title any automobiles or other operating vehicles in the business name?

YesNo

2. Is insurance coverage needed for owned automobiles?

YesNo

2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

2b. If yes, limits desired:

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?

YesNo

3a. If yes, how many?

3b. Do you verify they have liability coverage?

YesNo

3c. Limits? ($)

COMMERCIAL UMBRELLA

1. Do you need a Commercial Umbrella?

YesNo

1a. If yes, limit of liability needed? ($)

WORKERS' COMPENSATION INSURANCE

1. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo

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

2. Is Stop Gap Liability Requested? (Ohio Only)

YesNo

2a. If yes, please choose desired limits:

$100,000/$500,000/$100,000$500,000/$500,000/$500,000$500,000/$1,000,000/$500,000$1,000,000/$1,000,000/$1,000,000

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.

Signature

Or Enter Your Full Name as Signature:

Date:

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/

	Claim 1	Claim 2	Claim 3
Date of Occurrence
Description of Claim
Amount Paid
Status: Open or Closed

Personal Appearance Insurance Questionnaire