Insurance Application, Pigment and Skin Program

"*" indicates required fields

Name*

First Last

Business Name (DBA)*

The Business Name on the door.

Have we met?*

No, I'm new here

Yes, Returning Client

Yes, Re-Quote Please

How would you describe your business?*

Traditional Tattoo Shop

PMU Related Services and/or Training

Piercing Studio

Beauty, Esthetician, Hair, Nails, Spa Etc.

Independent Tattoo Artist

Independent Piercer

Nomad Tattooer, Conventions Only

Please describe your role*

Owner/Officer

Co Owner

Partner of Business

W2 Employee

Independent Contractor

CPA/Bookkeeper for the Insured

The Coverage you need:*

Professional and General Liability

Business Property and Contents

Machines and Valuable items Off Site

When would you like the policy to start?*

(Expiration Date, Deadline Date, Renewal Date)

MM slash DD slash YYYY

Email*

Mobile Phone*

Business Number

Can we text you?*

We'd like to keep you informed of the status of your Quote, Renewal, Service Requests, or Claims.

YES! Absolutely!

NO! Please, no.

Type of Entity*

The type of business entity.

The Formal Entity Name*

(Full legal business name. Example Tattoo the Zoo, LLC)

FEIN

Not required, but we may need it in the future

Your Birthdate

So we can celebrate with you!

YYYY

Location Address*

If you don't lease a physical location or you're a traveling artist, please enter a home/mailing address.

Street Address City State Zipcode

Mailing Address*

This is the address where you would like to receive mail.

Same as Location Address

Street Address City State Zipcode

When was your business established?

What is your Business Location(s) Situation?*

I lease a space/studio. Lease is in my name

Booth, I pay a flat amount each month

1099, Commission Split

Room Share Agreement

I'm 100% booth rental with a flat fee

Health Dept. approved "At Home Studio"

I lease multiple studio locations

W2 Employee, I need my own insurance

I own the Building and Lease it to my Studio

Upload Lease (If Any)

We'll review the insurance requirements, so the landlord is provided everything they need.

Drop files here or

Max. file size: 10 MB, Max. files: 10.

Primary Services*

Check all that apply

Traditional Tattooing

Piercing and Body Mods

Pigment Removal, Non Laser

Permanent Makeup using a machine

Microblading, NO Machine

Scalp Micropigmentation

Camouflage*

Microneedling, Microchanneling (ProCell)

None of These

Estimated Revenue for Primary Services*

Estimate revenue for the next 12 months. ONLY the ACTUAL cost of the Service. Do not include revenue from merch, jewelry, rent, or another source.

Offer Additional Services?*

Please select all services you currently offer or are considering in the future.

I DO NOT offer additional services

Lash Extensions or Tinting

Esthetician Work, Dermaplaning, Massage, Waxing

Traditional Makeup, Hair, FX Makeup, Nails

Injections, PRP, Fillers, Botox

Laser Technician

Electrolysis

Plasma / Fibroblast

Spray Tanning

Hyaluron Pen / Pressurized Injectables

Teeth Whitening

Medical Director

Estimated Revenue for Additional Services*

Revenue in the next 12 months. ONLY the ACTUAL cost of the Service. Do not include revenue from merch, jewelry, rent, or another source.

Do you sell Retail, Merch, Supplies?*

Yes

Estimated annual revenue from retail*

Do you Offer Training or Instruction?

Yes

I'm considering it

Types of Training or Instruction*

None of These

Fundamental PMU Training

Tattoo Apprenticeship

PMU Apprenticeship

Lash Extension Training

Bloodborne Pathogen Training

First Aid

Estimated Gross Revenue for Instruction Services*

Have you had at least 100 total hours of Fundamental Training?*

Including test, study, and practice time.

Yes

I'm in School, I graduate soon!

Who was your Instructor or School for Fundamental Training*

Please upload PMU training credentials

IF YOU ARE NEW TO US, please upload your certificate of completion for our records, thank you so much!

Drop files here or

Max. file size: 10 MB, Max. files: 1.

Business Property / Contents

Do you want coverage for contents at your Business Location?

Decor, Art, Furniture, Antiques, Reference Material, Merchandise and Retail Stock In the case of Fire, Vandalism, Theft?

YES, I lease a location and I want to cover my business contents

NO, I only want General and Professional Liability at this time

MAYBE, I am not sure, can we discuss it?

I understand and agree that I when I select "Liability Only" it is General and Professional Liability for my services, and NOT replacement coverage for my business contents, supplies, machines, income, papers and records etc.*

Yes, I agree

If you own the building, do you need coverage for it?*

Yes

Building Replacement Cost

We can include the building you own in our quote!

Have you made any "Tenant Improvements"?*

This includes the floors, lighting, molding, cabinetry, etc. What costs you to improve the space, to make it "Yours". If there is a fire, we want to put it back the way it was.

Yes

In the future

Total value of Tenant Improvements*

To Date, what is the cost of the Improvements YOU have made to your space? We want to put it back the way it was after a loss such as fire, smoke damage etc.

Do you need Tenant Glass Coverage?*

If you are responsible for the glass breakage or damage, select yes. Glass is not automatically covered; it must be added.

Yes, I am responsible for damages

No, my landlord covers the cost if broken, or I do not need this coverage

Total value of Contents / Business Property*

How much money would you need to replace your Furniture, Art, Computers, iPads, supplies, stock, merch, appliances, etc? It's okay to overestimate here.

Are you interested in Business Income Including Expense?*

This coverage is triggered AFTER 72 hours if your location is physically affected and you can not work and earn income.

YES

Business Income Coverage Limit*

How much income would you need PER MONTH (Maximum of 3 Months) if your location was shut down for more than 72 hours for payroll and expenses?

Do you want Coverage for Equipment and Supplies?*

Conventions, Education, Guest Spotting, etc.

Yes

Value at any given time of Off-Site Equipment*

Security features. (Check all that apply)*

Theft coverage may be included, but it is subject to a working central alarm system that's operational, notifies the 1st Responders and active at the time of loss.

None

Central Station Alarm (ADT etc)

Video System, Notifies the 1st Responders

Roll Down or Cage on Door & Windows

Smoke Detector

Fire Extinguisher

Deadbolts on all doors

Interior Fire Spinklers

Other

Name of Central Alarm Company*

Do you have more than one business location?*

Yes

Looking at Adding, Lets Talk

Square footage of your business*

The space you lease/responsible for/work in

Year Built*

Number of stories of the building*

Construction Type*

Roof Type*

Has there been any updates or inspections to the roof, HVAC, plumbing, or electrical?*

Please enter the Approx Year each was Updated OR Inspected below. Please ask the Property Manager or Landlord if you aren't sure, this information is Critical for Property Coverage.

Yes

I don't know

Roof*

Approximate Year

Plumbing*

Approximate Year

Electrical*

Approximate Year

HVAC*

Approximate Year

Within 5 miles of a coastline or large body of water?*

NOTE! Wind and Storm Coverage may be Excluded for the Eastern Side of the States. Please apply for flood program coverage to cover your business operations and property!

Yes

Do you offer beer or wine to your patrons?*

Yes

Do you comply with all City, County, Health and State Ordinances?*

This is a condition of our policy

YES

Have you ever had a Health Department Violation?*

YES

Stay current on Bloodborne Pathogen education?*

This is a condition of our policy if you are offering Tattooing, Piercing or PMU

YES

Do you obtain a signed release form for each client?*

This is a condition of our policy

YES

How long do you keep signed forms on file?*

We encourage cyber safety precautions for digital release forms and privacy precautions with paper forms.

up to 1 Year

1-5 Years

5-10 years, I want them in case I get sued

Do you check, photocopy and keep on file the client's ID?*

Per your state and county health dept guidelines. This is mandatory in California.

YES

Do you provide "After Care Info" after each procedure?*

This is a condition of our policy

YES

Do you always keep on file release forms for minors? (If any)*

YES

I don't work on minors

Are you prepared to handle fainting or nauseated patrons?*

This is a condition of our policy

YES

Are you 100% single use?*

YES

Do you always use barriers and cord wraps?*

This is a condition of our policy

YES

Add Sexual Abuse Misconduct Coverage for $200 per year?*

$200,000 Sub Limit

Yes

Add Assault and Battery Coverage for $200 per year?*

$100,000 Per Claim $200,000 Aggregate Limit

Yes

Add Communicable Disease Coverage for $150 per year?*

$100,000 Sub Limit

Yes

Add Cyber Liability / Data Breach Coverage for $50 per year?*

$25,000 Sub Limit

Yes

Raise the Professional Liability Limit to 1M for $350 per year?*

$1,000,000 Professional Liability Limit (from the included $500,000)

Yes

Do you want Terrorism coverage for a Minimum of $150 per year?*

Only certified acts are eligible for coverage through TRIA. A certified terrorism event is classified by the Secretary of the Treasury, Secretary of State, or the Attorney General.

YES

Do you want coverage in case they have an accident in their vehicle?*

Hired and Non-Owned Auto is $350.00 per Year with a $1,000,000 Limit! Business owners are responsible for damages if a crew member gets in an accident while running errands.

YES

Do you manufacture, mix, blend, re-label, or repackage products to sell under your own name?*

YES

Please describe the products you make or re-label

Does staff use their own cars for bank / supply / food runs?*

YES

Have you had any claims or losses in the last 5 years?*

YES

Please describe your claim and it's outcome*

Who referred you to us?

We have thank you surprises for them!

Which Affiliate Agency did you Apply with?

Comment Section

Anything you want us to know;

The above information is accurate, true to my knowledge.*

I affirm and certify that all the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void and will be cause for cancellation, whenever discovered.

Yes

Consent*

Like most insurance agencies, we use use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance, set you up for monthly payments (if chosen). New or updated information may be used to calculate your renewal premium.

I Agree

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