Acumen Insurance Beauty Program Application

PLEASE NOTE: COMPLETION OF THIS APPLICATION IS FOR QUOTATION PURPOSES ONLY AND DOES NOT PLACE COVERAGE IN FORCE














Yes
No

If Yes, please provide address













Yes
No



Yes
No

Yes
No


Property Information



Yes
No




Latest Updates if Building is Over 25 Years Old





Construction of Building


Concrete Block / Masonry
Brick Veneer over Wood
Frame / Siding

Steel Deck or Concrete
Wood Joists
Metal Clad

Yes
No



Yes
No

Yes
No

Yes
No

Yes
No

TO

Yes
No

Yes
No

Yes
No

Yes
No





Yes
No

Yes
No

Financial Information

USE THE FOLLOWING CATEGORY BREAKDOWNS TO HELP YOU DETERMINE YOUR “PROPERTY VALUES” BELOW

STOCK










EQUIPMENT









LEASEHOLDS / TENANTS IMPROVEMENTS










PROPERTY VALUES – COVERAGE YOU REQUIRE (TOTALS FROM THE ABOVE CATEGORIES)







THE QUOTATION WILL BE BASED ON THE ABOVE INFORMATION. PLEASE COMPLETE ACCURATELY

DESCRIPTION OF OPERATIONS


Yes
No


Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
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Yes
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Yes
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Yes
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No


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No


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No


Yes
No

Yes
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Yes
No


Yes
No

Yes
No

Yes
No


Yes
No

Yes
No



Yes
No


Yes
No

Crime Exposures



Yes
No

Equipment


Yes
No


Yes
No

Sterilization


Yes
No

Yes
No

PLEASE ATTACH A SUPPLEMENTARY PAGE OUTLINING ALL OF YOUR STERILIZATION PROCEDURES AS WELL AS POLICIES IN PLACE TO PREVENT CROSS-CONTAMINATION

Financial Information

Liability Information


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

Please provide approximate annual revenues for each of the following services:















Yes
No

Yes
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Yes
No

Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
No

Yes
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Yes
No


Yes
No



Yes
No

Yes
No

Yes
No


Yes
No


Yes
No



Yes
No



Yes
No


LASER/IPL/RF APPLICATION


Yes
No

Please advise if you provide the following Laser/IPL operations:


Yes
No

Yes
No

Yes
No

Please provide all operators who provide Laser/RF/Light treatment and their experience:

Name of Persons providing Laser/IPL Treatments Years of Education Years of Experience Any prior claims made against each individual Please give details

1 2 3 4 5 6

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No


Complete this section for all Laser/IPL/RF systems

Make Model & Serial Number Age Years Cost to Replace Today Including Attachments/Hand Pieces

Yes
No

Yes
No



Yes
No


Yes
No

MASSAGE THERAPY


Yes
No

Yes
No


Yes
No


Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

ELECTROLYSIS, ACID PEELS & MICRODERMABRASION


Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No


Yes
No


1 2 3 4 5 6

PERMANENT MAKEUP


Yes
No





Yes
No


Yes
No

Yes
No

Yes
No


Yes
No




Yes
No

PLEASE ATTACH A SUPPLEMENT PAGE OUTLINING ALL OF YOUR STERILIZATION PROCEDURES AS WELL AS POLICIES IN PLACE TO PREVENT CROSS-CONTAMINATION

TANNING OPERATIONS


Yes
No
Equipment #of Units Intensity Manufacturer Type of Timer Where are timing controls located?
Beds
Booths
Facial Units
Spray Booths
Air Brush




Yes
No

Yes
No


Yes
No

TANNING PROCEDURE


Yes
No

Yes
No

Yes
No

Yes
No



Yes
No

Yes
No

Yes
No

Yes
No

Yes
No


Yes
No

Other Services / Products


Yes
No
If Yes, please attach a copy of course outline including instructors qualifications and number of students

Please provide a brochure of your operations, if available, when submitting this application.

List of all People who provide the above operations





Name Years of Education Years of Experience Operations Type

Yes
No



FAILURE TO ANSWER ALL QUESTIONS MAY RESULT IN A DELAY IN PROCESSING YOUR SUBMISSION

Any person who knowingly and with intent to defraud any insurance company or another person, files and application containing any false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects this person to criminal and civil penalties.

PRIVACY CLAUSE

Our brokerage and the insurance industry have a solid track record of respecting your right to privacy and safeguarding your personal information. As a result of federal legislation, we’ve further strengthened our privacy commitment by informing you of why and how we collect, use and disclose your personal information. You can be assured that we’ll only handle your personal information in a manner that a reasonable person would consider appropriate in the circumstances.

PLEASE NOTE:

The applicant agrees to notify the company of any material changes in the answers to the questions on this questionnaire which may arise during the course of this policy issued and further understands that claims may be denied if information regarding these material changes was not provided. The purpose of this questionnaire is to assist in the underwriting process. Information contained herein is specifically relied on in determination of insurability.

The under-signed, therefore, warrants that the information contained herein is true and accurate to the best of his / her knowledge, information, and belief. The questionnaire and the application shall be the basis of any insurance policy that be issued and will be part of such policy.

A consumer report containing personal, credit, factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal, extension or variation thereof. Signing of this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.

The Client hereby acknowledges that by completing and returning the application to Acumen Insurance Group Inc., you agreed to and consent to the collection, use and disclosure of such information, including any personal information, by AcumenInsurance Group Inc. for the following purposes:

  • Communicating with you
  • Assessing your application for insurance
  • Disclosing information to the Insurance Companies
  • Negotiating, maintaining or renewing insurance on your behalf
  • Providing claims assistance and service
  • Advising you of other products or services
  • Complying with regulations and legal authorities