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Shop Name: *
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| Shop Owner Name: * |
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| Best Phone#: * |
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| Physical Address: * |
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| E Mail: * |
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| Years in Business: * |
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| Type of ownership: * |
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| How many shows per year?: * |
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| Currently Insured?: * |
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| Name of Carrier: |
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| Prior claims or losses?: * |
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| Desired effective OR renewal date: |
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| General Liability Limits requested:* |
General Libility is coverage for an insured when negligent acts result in bodily injury and/or property damage.
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| Professional Liability Limit requested: * |
Professional Liability (E&O or Errors & Omissions) protects the insured from claims if your client holds you responsible for errors or your failure to perform the work as promised.
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| Annual Shop Gross Receipts/Sales: * |
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| GENERAL INFORMATION: |
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| Name Landlord as Additional Insured?: * |
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| Are you in compliance with City, County, State and Health Dept. ordinances?: * |
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| Bloodborne Pathogen Certified?: * |
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| Do you Spore Test per State Standards?: * |
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| Do you always obtain a signed release/medical history form on each client?: * |
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| Do you check and photocopy client ID and keep on file?: * |
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| Is staff trained to handle nauseated, fainting, or "under the influence" patrons?: * |
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| You manufacture, mix or blend products for sale/resale?: * |
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| Is your location maintained in a sanitary manner?: * |
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| Use at least one new pair of gloves with each procedure?: * |
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| Autoclave Make and Model: * |
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| TATTOO OPERATIONS: |
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| Tattooing Offered?: * |
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| Total Tattoo Artists in shop: * |
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| Years of Industry Experience: * |
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| Provide an "aftercare form" after each NEW client procedure?: * |
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| Tattoo Minors under 18?: * |
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| Offer Permanent Makeup?: * |
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| Offer Electrolysis, Esthetician or Acupuncture Svcs.?: * |
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| Do you reuse needles?: * |
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| Use all single use/disposable needles?: * |
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| All pigments used "Industry Standards"?: * |
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| Dispose of all pigments after each procedure?: * |
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| Use UV/Glow in dark or do "blacklight tattoos": * |
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| Ink cups and cord wraps disposable?: * |
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| PIERCING OPERATIONS: |
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| Piercing Offered?: * |
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| Total Piercers in shop: * |
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| Years of Industry Experience: * |
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| Use a piercing gun?: * |
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| Genital Piercings offered?: * |
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| Perform Sub/Micro Dermal Implants?: * |
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| Do Branding?: * |
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| Do Scarification?: * |
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| Pierce minors with consent form?: * |
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| Use New-Industry approved jewelry for each procedure?: * |
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| Provide a written "aftercare form" for each procedure?: * |
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| PROPERTY INFORMATION: |
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| Is this your only location?: * |
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| Occupancy Type: * |
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| Building coverage amount (if owned): |
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| Square footage you occupy: * |
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| Type of building: * |
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| Approx age of building: * |
If building is over 25 years old, what approximate year were the following updated?
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| Wiring/Electrical: |
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| Plumbing: |
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| Heating-A/C: |
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| Roofing: |
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| How many stories?: * |
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| Central Station alarm on shop?: * |
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| Alarm serviced by: |
There is NO theft coverage if shop doesn't have a central alarm
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| Are there sprinklers covering 100% of the shop?: * |
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| Sell clothing or jewelry?: * |
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| Typical Inventory value: |
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| ATM in shop?: * |
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| Total value of business/shop contents (property): * |
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| Monthly Business Income Required (in case of a loss): |
(This is optional coverage)
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By selecting today's date, it is written warranty that all statements made by you on this application are true and correct to the best of your knowledge. This can also act as your signature if you choose to get the coverage after reviewing detailed quotes. You are ONLY obtaining quotes at this time:*
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| Comments? Questions? Enter them here!: |
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| Protect your info!: * |
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*IF YOU CLICK SUBMIT AND IT DOES NOT RETURN TO OUR HOME PAGE, WE MAY NOT HAVE RECIVED YOUR REQUEST *
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