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Step
1
of
11
9%
Is this a home-based business?
(Required)
Do you work from a home office and/or exclusively do outcalls to your customer's homes?
Yes
No
Oh no! We're not offering any new proposals for home-based businesses. We can't help with your insurance coverage.
Do you perform any of the following services?
(Required)
Acid-based tattoo/pigment removal
Branding (burns with hot irons)
Cryotherapy (with chamber / tube)
Fire Cupping
Fish Pedicure
Inkless Stretch Mark Camouflage with "Serum"
Intimate Lightening
Scarification
Suspensions
Tattoo/Pigment Removal with products that contain acids
Vaginal Rejuvenation
Vaginal Steaming
Vajacial
Wet Cupping (with blood)
Yoni Steaming
Yes
No
Oh no! We're not offering any new proposals for businesses that perform these services. We can't help with your insurance coverage.
Do you perform any of the following services?
(Required)
BB Glow
Botox Injections
Colon Hydrotherapy
Dermal Filler Injections
Hyaluron Pen
Hormone Therapies (injected or otherwise)
IV Hydration
Jet Plasma
Mesotherapy
PEPfactor Hair Rejuvenation
Plasma Fibroblast
Plasma Pen
PRP Injections (platelet-rich plasma)
Sclerotherapy
Spot Plasma
Vitamin Therapies (injected or otherwise)
Yes
No
Do you have a medical director (AKA "supervising physician")?
(Required)
If you are an MD, DO, or NP; answer "yes".
Yes
No
Oh no! We're not offering any new proposals for businesses that perform these services without a medical director. We can't help with your insurance coverage.
Do you perform any of the following services?
(Required)
Acupuncture
Body Contouring
Chemical Peels - Medical Grade
Chiropractic
Nutritional Counseling / Consultation
Yes
No
Staffing
List everyone that works at your business. If you haven't hired them yet (and don't know their name), you can list by job title or made-up names. Listing by name helps to avoid overcharging you.
Click Add Name to add each person
.
Name
What does this person do at your business? (check all that apply)
This person is a/an...
Actions
Edit
Delete
There are no
Names.
Add Name
Maximum number of names reached.
Are you a school with students doing hands-on work?
(Required)
Yes
No
Do you sell any products under your own label?
(Required)
Yes
No
Do you physically manufacture or repackage any of these products?
(Required)
Yes
No
Do you directly import any of these products from outside North America?
(Required)
Yes
No
Are all students working under direct in-person supervision of an instructor?
(Required)
Yes
No
Do all instructors have at least three years experience in the services they are teaching?
(Required)
Yes
No
Oh no! We require direct in-person supervision of students. We can't help with your insurance coverage.
Oh no! We're not able to help schools with instructors so new to the industry. We can't help with your insurance coverage.
Business Locations
Include locations where you regularly work (at least once per week).
Click the "add location" button to add business locations and provide the requested info
.
Address
Include property coverage at this location?
Contents Coverage
Building Coverage
Actions
Edit
Delete
There are no
Locations.
Add Location
Maximum number of locations reached.
Who are we covering?
Answer regarding yourself and your business--if you're working inside of a larger business but don't own it, indicate that you're an individual.
Your Name
(Required)
First
Last
Is your business set up as an "entity" like an LLC or a Corporation?
(Required)
Yes
No
Entity Name
(Required)
This is the official name on your business records
Entity Type
(Required)
Select the one that matches the end of your official "entity name"
Corp
Inc
LLC
Ltd
Partnership
PC
PLLC
List the name(s) of all partners
(Required)
Have you created a "DBA" or "T/A" name different from the name(s) above?
(Required)
A "DBA" or "T/A" name is used when you are "doing business as" a name that doesn't match your own name, or the name of your "entity"
Yes
No
DBA or T/A name
(Required)
How can we reach you?
Email
(Required)
Phone
(Required)
Website
Mailing Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business History
Year Started in Business
(Required)
OK to indicate the year you started working in this industry (which could be earlier than the current business actually opened).
Estimated total annual (yearly) sales
An estimate is fine. This won't impact your policy premium.
Have any service providers been the subject of a license revocation, suspension, or sanction related to the covered services in the last five years?
(Required)
This relates to professional licenses; not drivers' license.
Yes
No
Have there been any liability (lawsuit) claims in the last five years (whether or not insured)?
(Required)
Yes
No
Describe any such liability (lawsuit) claims
(Required)
Include dates, descriptions, and amounts paid (if any)
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