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Tanning Salon Program Application

APPLICANT INFORMATION (* - required fields)
* Company Name:
* First Name:
* Last Name:
* Mailing Address:
 
* City:
* State:
* Zip:
* Phone:
E-mail:
Fax:
* Applicant is a: Individual
Partnership
Corporation
Other (specify)
* FEIN or SSN:
TYPE OF BUSINESS
Tanning Salon
Tanning Salon with Massage
Tanning Salon w/ Additional Services
PROPERTY COVERAGE/BUILDING INFORMATION
PREMISES INFORMATION
Location Building Address (Include City, State, and Zip Code)
*
* Construction: Frame Brick Other
* Square Ft.:
* Stories:
% of Building Occupied:
Who are the other occupant's?:
* Age of Building:
* Premises sprinklered: Yes No
Building Improvements:
Wiring Year:
Roofing Year:
Plumbing Year:
Heating Year:
PROPERTY LIMITS VALUATION
Building:
Inventory/Business Property:
Property Deductible Options 500 1000
ADDITIONAL INTERESTS
Mortgagee Name:
Mortgagee Address:
Loss Payee Name:
Loss Payee Address:
GENERAL LIABILITY SECTION:
PROFESSIONAL LIABILITY AUTOMATICALLY INCLUDES $1,000,000
* PER OCCURENCE/AGGREGATE LIMITS
$1,000,000/$2,000,000 $1,000,000/$3,000,000
WORKERS COMPENSATION
* Payroll Tanning / Beauty / Massage:
(estimated payroll of employees anually)
Payroll Other:
UMBRELLA LIMITS
$1,000,000
Other
RECOMMENDED OPTIONAL INSURANCE COVERAGE
Employment Practice Liability:
Employee Crime Coverage:
Earthquake:
Automobile (Hired & Non-owned):
OPERATIONS
* 1. How many years has the applicant been in business?:
* 2. Number of Tanning Beds?:
* 3. Massage Therapists (full time if any)?:
* 4. Massage Therapists (independent contractors)?:
* 5. Other Employees and job descriptions:
* 6. Any other independent contractors?:
* 7. Are all customers given information about the types of rays and the potential sensitivity?: Yes No
* 8. Are records kept on each tanning customer for each visit and exposure time?: Yes No
* 9. Are eye protective goggles requires for all users?: Yes No
* 10. Does an employee sanitize beds after every use?: Yes No
* 11. Does the customer sign a waiver of liability before using tanning beds?:
If yes, provide a copy of the waiver.		 Yes No
* 12. Do you provide massage therapy?: Yes No
* 13. Has any massage therapis even been sued for malpractice?: Yes No
* 14. Do the clients complete an application before the first massage?: Yes No
* 15. Does the applicant provide electrolysis services?: Yes No
a. What procedure is used to dispose probes?:
b. What type of post treatment instructions are give to patients:
c. Are reactions to electrological procedures recorded?:
* 16. has any policy or coverage been declines, cancelled or non-renewed in the past 3 years?: Yes No
* 17. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?: Yes No
* 18. During the last 10 years, has any applicant been convicted of any degree of the crime arson?: Yes No
* 19. Any uncorrected fire code violations?: Yes No
*20. Expiration Date:
*21. Current Insurance Company:
*22. Type of Timer:
*23. Bed Manufacturer:
*24. What management software do you use?
LOSS HISTORY
Check here if none Loss History Reports attached
Date of Loss Description Amount Paid
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 SUBMITTING
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 sharing. You are advised that you may make a request within reasonable time after receipt of this Notice for a disclosure by Lamb, Little & Co. of the nature and scope of the investigation requested.
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