Beauty/Esthetics/Spa Insurance Application Form

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- Step 1 of 9

Are you a broker? *

Brokerage Name

Brokerage Address

Broker City

Broker Province

Broker Country

Broker Postal Code

Broker Telephone

Broker Email

Business Name

Location Address

Location City

Location Province

Location Country

Location Postal Code

Mailing Address

Mailing City

Mailing Province

Mailing Country

Mailing Postal Code

Owner/Operator

Bus #

Fax

Email *

Cell # *

Res #

Alternative Contact

Alternative Phone

Alternative Email

Website / URL

Current Insurance Company

Expiry Date of Current Policy

Retroactive Date of Current Policy

Target Premium $

Number of years in business?

Have you ever been cancelled for nonpayment?

PROPERTY INFORMATION

Describe your location (strip plaza, shopping mall, etc.)

Building Age (year built):

No. Of Stories

Do you own the building?

Total Area of Building (sq. ft.)

Total Area of your Facility (sq. ft.)

Sprinkler System

Monitored Alarm

Fire Hydrants within 500 feet

Is there Any Bar/Restaurant Adjacent to your operation?

Does your location include a basement?

Describe precautions taken to avoid slips and falls at entrances

Do you have any equipment stored offsite? (i.e. home office)

Please describe

CONSTRUCTION OF BUILDING

FIRE-RESISTANT: Structures/buildings must be made of reinforced concrete or protected steel.

NON-COMBUSTIBLE: Building has exterior walls made of masonry materials, such as brick, concrete, hollow concrete block, stone, or other similar materials, with floors and roof constructed of metal.

MASONRY: Brick veneer & combination of steel, concrete and wood.

FRAME: Wood, tar and brick or similar materials.

LATEST UPDATES

UPDATE TYPE

COMPLETED

TO CODE

Roof

If the building 20+ yrs old, this line is required

Roofing Update Type

FULL
PARTIAL

Roofing Year Update

Roofing To Code

Heat

If the building is 35+ yrs old, this line is required

Heat Update Type

FULL
PARTIAL

Heating Year Update

Heating To Code

Plumbing

If the building is 35+ yrs old, this line is required

Plumbing Update Type

FULL
PARTIAL

Plumbing Year Update

Plumbing To Code

Electrical

If the building is 35+ yrs old, this line is required

Electrical Update Type

FULL
PARTIAL

Electrical Year Update

Electrical To Code

STOCK

EQUIPMENT:

Shampoo, Dyes, Gloves $

Lotion, Polish, Oils, etc. $

Stock Other $

Computers/Laptops $

Scissors & Other Tools $

Laser/IPL Equip $

Styling Stations/Furniture $

Machines (non-laser/IPL $

Machines $

Equipment Other $

LEASEHOLDS

Existing Tenants Improv. $

Styling Chairs (affixed) $

Offices/Built-ins $

Washrooms/Showers $

Phone/Alarm Sys. $

Construction $

Wall Coverings/Flooring $

Treatment Rooms $

Leasehold Other $

TOTAL CONTENTS $ (including all stock, equipment & leaseholds above)

BUILDING REPLACEMENT VALUE

Sq. Ft. of Building

Cost / Sq. Ft. $

Total Building Replacement Value $

DID YOU KNOW:

Many people underestimate and therefore underinsure their property limits. Make sure you list how much it would cost to replace all of the above items today. To help estimate your Leasehold Improvements, you can multiply your square footage by $40-45 (minimum $/sq. ft. used for this industry).

OTHER BUSINESS(ES)

Do you own/operate or rent space to other businesses?

Total annual rental income:

Describe type(s) of business:

EQUIPMENT

Do You Have Modified/Rebuilt/Used Equipment?

If Yes, % used:

Age:

Is Equipment Inspected Daily?

Who Does Maintenance?

LIABILITY INFORMATION

Liability Limit Requested:

$2,000,000
$3,000,000
$4,000,000
$5,000,000

DESCRIPTION OF OPERATIONS

Any client under the age of 18?

If yes, do parents stay on premise?

Do you ever serve alcohol?

If yes, is it complimentary or sold?

Complimentary
Sold

If sold, what is the annual revenue?

Are staff Smart Serve licensed or equivalent?

Are any operations or activities done away off premises?

Describe:

Is all staff certified/educated/trained in the services they perform?

WET AREAS

Showers #

Pools / Whirlpools #

Steam Rooms #

Hydrotherapy Tubs #

Vichy Showers #

Wet Saunas #

Dry/Infrared Saunas #

Hyperbaric Chambers #

Volcanic Rock Room(s) #

Non-Slip Flooring?

Rubber Mats In Halls?

Other:

SURVEY OF OPERATIONS

TYPE 1

Select all Type 1 Services that apply

Hair
Ear/Body Piercing
Body Wraps
Manicure Pedicure
Facials/Make Up
Nails (Gel/Acrylic)
Waxing/Sugaring
Product Sales

Type 1 Annual Receipts (**MUST HAVE ESTIMATE IN ORDER TO QUOTE):

TYPE 2

(Note: Operations marked with an asterisk – Please Complete Attached Page)

Select all Type 2 Services that apply:

Lashes (lift/perming)
Lashes (tinting/extensions)
Teeth Whitening
Brow Lamination
Massage
Reflexology/Reiki
Electrocoagulation
Acid/Glycolic Peels
Microdermabrasion
Electrolysis
Radio Frequency
Tanning Bed

Type 2 Annual Receipts (**MUST HAVE ESTIMATE IN ORDER TO QUOTE):

MASSAGE / REFLEXOLOGY / REIKI OPERATIONS

1. Name

1. Type of massage performed

1. Yrs of exp

1. RMT Yes or No?

2. Name

2. Type of massage performed

2. Yrs of exp

2. RMT Yes or No?

List all types of massage offered:

Do you discuss and keep copies of all health information/service records on file for at least 2 yrs? **

Is a signed waiver kept on file for at least 2 yrs? **

Minimum age of clients for massage services:

** MINORS: You need to keep these records/waivers on file for 2 yrs after client turns 18

ELECTROLYSIS / PEELS / MICRODERMABRASION OPERATIONS

Do you use an autoclave to sterilize equipment?

Does all staff wear surgical gloves when performing services?

Do you use disposable tips for each new client?

Do you provide Medium Peels?

Do you provide Deep Peels?

Do you discuss and keep copies of all health information/service records on file for at least 2 yrs? **

Is a signed waiver for ELECTROLYSIS / PEELS / MICRODERMABRASION and kept file for at least 2 yrs? ** Y/N

** MINORS: You need to keep these records/waivers on file for 2 yrs after client turns 18

Minimum age of clients for electrolysis:

Minimum age of clients for peels:

Minimum age of clients for microdermabrasion:

TANNING OPERATIONS

Tanning Beds #

Are you a full member of SmartTan Association (or other tanning association)?

Are all staff trained or certified through SmartTan or equivalent certifying body?

Are clients given tanning instruction?

Minimum age of tanning clients:

Are goggles supplied and required to be used?

Do you complete a skin analysis for every client?

Is touching of clients allowed by staff?

Are beds cleaned after every use?

Minimum time allowed between tans/client:

Do all clients sign waivers?

Beds #

Booths #

Spray Booths #

Air Brush Units #

Where are timing controls located?

Who sets timers?

Do electricians service the equipment? YES OR NO

Are any beds coin operated? YES OR NO

Average age of beds:

Outside dryer vents cleaned at least every 6 months?

Are beds/Booths protected by ground fault interrupted (GFI) circuits?

Type 3

(Note: Operations marked with an asterisk – Please Complete Attached Page)

Select All Type 3 Applications That Apply

Laser Treatments
IPL Treatments
Cold Laser
Skin Needling
Cupping
Botox/Collagen
Other Injected FIllers
Scierotherapy
Micropigmentation/Microblading
Plasma Rich Platelets (PRP)
Teaching/Instructional
Other

Other Services:

Type 3 Annual Receipts (**MUST HAVE ESTIMATE IN ORDER TO QUOTE):

MICROPIGMENTATION (PERMANENT MAKE UP)

Select All Micropigmentation Applications that Apply

Eye Liner (Top &/or Bottom Lids)
Lips
Scalp
Eye Brows
Areolas &/or Scars
Other

Other (Please Describe):

Tattoo Removal *MUST describe all methods * -

Percentage of Services Performed – Cosmetic Procedures % (i.e. liner, brows, lips, etc.)

Percentage of Services Performed – Corrective Procedures % (i.e. tattoo removal, scars, areolas)

Manufacturer, Make & Model of Pen/Instrument Used?

Manufacturer(s) Of Pigment Used:

Are All Machines & Pigments Manufactured Within North America?

If no, please advise where:

SKIN NEEDLING

Needle Depth Used:

Make and Model(s) of Skin Needle Machine Used:

Do you keep copies of all needling client appointment/service records on file for at least 2 yrs? **

Is a waiver for needling signed and kept on file for at least 2 years?

** MINORS: You need to keep these records/waivers on file for 2 yrs after client turns 18

TEACHING/INSTRUCTIONAL COURSES

What services are taught?

Are certifications issued to students?

Do you charge tuition/fees?

If yes, what do you charge?

What are the annual gross receipts?

How many students do you certify each year?

How many students participate in a course?

How long are the courses?

How many hours must a student complete to graduate?

How many courses are offered each year?

Is there a final exam?

Do students offer services to the public?

Teaching/Instructional Courses Employees/SubContractors

Teacher 1 Name

Teacher 1 Service taught

Teacher 1 Yrs of Exp.

Teacher 1 Certification

Teacher 2 Name

Teacher 2 Service taught

Teacher 2 Yrs of Exp.

Teacher 2 Certification

Teacher 3 Name

Teacher 3 Service taught

Teacher 3 Yrs of Exp.

Teacher 3 Certification

Teacher 4 Name

Teacher 4 Service taught

Teacher 4 Yrs. of exp

Teacher 4 Certification

Do you have more than 4 teachers?

Please upload a list of additional teachers noting their services taught, years of experience and certifications.

Click or drag a file to this area to upload.

Plasma Rich Platelets (PRP)

What are the receipts for the Plasma Rich Platelets services in the last 12 months?

Do all employees/sub-contractors have their Blood Borne Pathogens certification?

Does all staff wear surgical gloves when performing services?

Describe your sterilization/cross-contamination prevention procedures:

How do you dispose of any biological waste?

Do you have PRP clients sign pre & post treatment info? (MUST submit copies)

Please upload a copy of your pre and post-treatment info you require clients to sign for PRP treatments.

Click or drag a file to this area to upload.

What is the minimum age of clients for Plasma Rich Platelets services?

Has any staff (including sub-contractors) had any claims again them in the last 5 years? Yes or No

Do you keep copies of all client appointment/service records on file for at least 2 yrs? Yes or No

Is a signed waiver kept on file for at least 2 yrs? Yes or NO

PRP TREATMENT SERVICES

Select All PRP Treatment Services That Apply

Hair Restoration
Neck Rejuvenation
Pain Management
Cellulite Reduction
Vaginal Rejuvenation
Injury Treatment
Erectile Dysfunction
Facial Rejuvenation
Other

Other please describe:

PRP EMPLOYEES/SUB-CONTRACTORS (MUST SUBMIT CERTIFICATES)

RN = Registered Nurse NP = Nurse Practitioner RPN = Registered Practical Nurse D = Doctor O = Other

1 PRP Employee name

1 PRP Yrs. of exp.

1 PRP Services performed

1 PRP List all certifications

1 PRP Employee role

1. PRP other: please describe

2 PRP Employee name

2 PRP Yrs. of exp.

2 PRP Services performed

2 PRP List all certifications

2 PRP Employee role

2. PRP other: please describe

3 PRP Employee name

3 PRP Yrs. of exp.

3 PRP Services performed

3 PRP List all certifications

3 PRP Employee role

3. PRP other: please describe

4 PRP Employee name

4 PRP Yrs. of exp.

4 PRP Services performed

4 PRP List all certifications

4 PRP Employee role

4. PRP other: please describe

Do you have more than 4 PRP Employees or Sub Contractors?

Employee List Upload

Click or drag a file to this area to upload.

Employee Certificate Uploads

Click or drag files to this area to upload. You can upload up to 100 files.

LASER/IPL APPLICATION

SERVICES OFFERED

Select All Laser/IPL Applications That Apply

Laser
IPL
Cold Laser
Acne
Psoriasis & Vitiligo
Tattoo Removal
Skin Resurfacing
Pigmented Lesions
Hair Removal
Vascular Lesions
Leg Veins
Re-Pigmentation
Other

Other Laser/IPL services offered:

What Skin Types (Based on Fitzpatrick Scale) do you provide services for:

What percentage of treatments are performed on Skin Types 5 & 6? %

Do you always follow laser/IPL manufacturer guidelines regarding patch test & wait times?

Do you keep copies of all client appointment/service records on file for at least 2 yrs? **

Is a signed waiver kept on file for at least 2 yrs? **

** MINORS: You need to keep these records/waivers on file for 2 yrs after client turns 18

Do you have laser/IPL clients sign pre & post treatment info? (MUST submit copies)

Please upload a copy of your pre and post-treatment info you require clients to sign for Laser/IPL Treatments.

Click or drag files to this area to upload. You can upload up to 10 files.

Minimum age of clients for laser/IPL treatments:

How often do you calibrate your machines?

Do you provide any laser/IPL treatments away from premises?

List:

MACHINES

Make 1 e.g. Syneron

Model 1 e.g. Elos Plus

Model Year 1 e.g. 2014

Replacement Cost 1 (CAD)

Make 2

Model 2

Model Year 2

Replacement Cost 2 (CAD)

Make 3

Model 3

Model Year 3

Replacement Cost 3 (CAD)

Has all equipment listed above been licensed for use by Health Canada?

*All Lasers, IPL Machines etc. must be licensed for use/sale by Health Canada to be legally used and insured within Canada. You can check your machine(s) at http://webprod5.hc-sc.gc.ca/mdll-limh/prepareSearch-preparerRecherche.do?type=active&lang=eng or call (613) 957-7285

LASER/IPL TECHNICIANS (MUST ATTACH CERTIFICATES)

1. Technician name

1. Technician Yrs of exp.

1. Technician year certified

1. Technician services

1. Fitzpatrick Scale Skin Types

1.Technician prior claims y/n?

2. Technician name

2. Technician Yrs of exp.

2. Technician year certified

2. Technician services

2. Fitzpatrick Scale Skin Types

2. Technician prior claims y/n?

3. Technician name

3. Technician Yrs of exp.

3. Technician year certified

3. Technician services

3. Fitzpatrick Scale Skin Types

3. Technician prior claims y/n?

Technician Certificate Uploads

Click or drag files to this area to upload. You can upload up to 50 files.

ADDITIONAL OPERATIONS (NOTE: If any of the below operations are offered the submission may be declined)

Select All Additional Operations That Apply

BB Glow
Hypnotherapy
Osteopathy
Mesotherapy
Vaginal Tightening/Rejuvenation
Hyaluron Pen
Acupuncture
Plasma-Pen
Cryotherapy Chambers

ADDITIONS TO THE POLICY

ADDITIONAL INSURED 1: (Provide full name, address and interest in the policy * i.e. Landlord, contractor, etc.)

ADDITIONAL INSURED 2: (Provide full name, address and interest in the policy * i.e. Landlord, contractor, etc.)

LOSS PAYEE 1: (Provide full name, address and interest in the policy * i.e. leasing co., mortgagee, etc.)

LOSS PAYEE 2: (Provide full name, address and interest in the policy * i.e. leasing co., mortgagee, etc.)

CLAIMS HISTORY

Has the company &/or staff had claims against them in last 5 years?

1. Date of loss

1. Loss Details

1. Amount Paid/Reserve

I understand and agree that any policy issued will be based upon the information contained in the application and any related forms. I understand that any forms or other material submitted with the application constitute part of my application for insurance. I further understand and agree that any misrepresentation or failure to provide true and accurate information may result in the voiding of and/or denial of claims under any policy issued at the option of the company. By submitting this application and any related forms to Sports & Fitness Insurance Canada, you provide Trothen & McConkey Insurance Broker Ltd. with your consent to the collection, use and disclosure of your personal information, including that previously collected, for the purpose of: communicating with you; assessing your application for insurance and underwriting your policies; evaluating claims; detecting and preventing fraud; analyzing business results; and acting as required or authorized by law.

Title

APPLICANT NAME *

First

Last

Date

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Beauty/Esthetics/Spa Insurance Application Form

PROPERTY INFORMATION

CONSTRUCTION OF BUILDING

LATEST UPDATES

UPDATE TYPE

COMPLETED

TO CODE

Roof

Heat

Plumbing

Electrical

BUILDING REPLACEMENT VALUE

DID YOU KNOW:

OTHER BUSINESS(ES)

EQUIPMENT

LIABILITY INFORMATION

DESCRIPTION OF OPERATIONS

WET AREAS

SURVEY OF OPERATIONS

TYPE 1

TYPE 2

MASSAGE / REFLEXOLOGY / REIKI OPERATIONS

ELECTROLYSIS / PEELS / MICRODERMABRASION OPERATIONS

TANNING OPERATIONS

Type 3

MICROPIGMENTATION (PERMANENT MAKE UP)

SKIN NEEDLING

TEACHING/INSTRUCTIONAL COURSES

Teaching/Instructional Courses Employees/SubContractors

Plasma Rich Platelets (PRP)

PRP TREATMENT SERVICES

PRP EMPLOYEES/SUB-CONTRACTORS (MUST SUBMIT CERTIFICATES)

LASER/IPL APPLICATION

MACHINES

LASER/IPL TECHNICIANS (MUST ATTACH CERTIFICATES)

ADDITIONAL OPERATIONS (NOTE: If any of the below operations are offered the submission may be declined)

ADDITIONS TO THE POLICY

CLAIMS HISTORY

Areas of Expertise

Learn More

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