Tattoo & Body Piercing Supplemental Application

Name

Effective Date

Mailing Address

Location Address

City

State

Zip Code

Country

Website

Phone/Mobile

Main Contact

Title

Current Expiration Date

Phone/Mobile

Type of Entity

Expiring Carrier

Years In Business

Expiring Premium

Need by Date

Locations 1

Address

City

State

Zip Code

Locations 2

Address

City

State

Zip Code

Locations 3

Address

City

State

Zip Code

Loss History

Have there been any gaps in coverage in the last three years?

Have there been any losses in the last three years?

Please Explain:

Services

Tattooing

Piercing

Cosmetic Tattooing

Saline Removal

General Liability

Each Occurrence
General Aggregate $2,000,000
Products and Completed Operations $1,000,000
Personal and Advertising Injury Limit $1,000,000
Damage to Premises Rented to you $300,000
Medical Expense Limit $5,000
Professional Liability $1,000,000
*Standard damage to premises rented to can be raised to up to $1m, if required by written contract

Communicable Disease $25,000/$25,000
Assault & Battery $25,000/$25,000
Sexual Abuse & Molestation $25,000/$25,000
Worldwide Coverage Endorsement ($50 per artist using that coverage) Artists

Personnel

Tattoo Artist

Piercing

Cosmetic Tattooing

Scheduled Artists

*If there are more than 12 artists, please add an additional page with artist information

Full Name

Length of Employment

Years of Experience

Additional Questions

Is there a weapon kept on the premises

Yes

Are all artists required to maintain the relevant licenses and/or certifications?

Yes

Do you have blood-borne pathogen training?

Yes

Are new disposable needles/supplies used for each new client?

Yes

Do you require waivers from your clients prior to providing services?

Yes

Are pre-employment background checks performed on all employees?

Yes

If yes, do you follow all rules and regulations around tattooing minors?

Yes

What areas?

Yes

Do you pierce minors with parental consent?

Yes

Do you have rules or guidelines related to services provided to intoxicated persons?

Yes

What are the minimum years of experience for an artist to come to work for you?

Yes

Are you licensed by the state or city and meet all city or state regulations?

Yes

Do you have written sterilization, sanitation, and safety standards?

Yes

Do you verify the age of clients prior to providing services?

Yes

Do you provide written instructions for care/maintenance to all clients?

Yes

Do you Tattoo Minors with parental consent?

Yes

Do you tattoo eyeballs or other sensitive areas?

Yes

Do you perform body piercing?

Yes

Explanation:

Please indicate what body parts are performed on:

Do you have any other operations besides tattoo and body piercing?

Please explain:

Property

*There may be a separate W/H Deductible based on location. Additional locations may be submitted on a separate sheet.

Location #

Coverage

Limit

Form

Special X theft

Coinsurance

80%

Construction

Frame

Building #

Year Built

Roof year

HVAC year

Plumbing year

Electrical year

# of Stories

Is the building owned or leased?

Yes

Fire Alarm?

Yes

Central Station burglar alarm?

Yes

Distance to Nearest Fire Department

Yes

Sprinklered?

Yes

Video Cameras?

Yes

Distance to Nearest Hydrant

Yes

Have you or anyone with a financial interest in the property been convicted of arson, fraud, or other crime related to the loss of property owned now or during the past five years?

Yes

I CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS ACCURATE AND COMPLETE.

Any individual who, intending to deceive or with the knowledge that they are aiding in an act of fraud against an insurance company, submits an application or files a claim containing false or misleading statements may be held liable for insurance fraud, leading to potential fines and/or imprisonment.

Applicant Name

Name of Producing Agent

Title

Date

Agent Name

Agent Address

Additional Interest

Interest

First Name

Last Name

Address

City

State

Zip Code

info@inksurancepro.com

info@inksurancepro.com

Loss History

Services

General Liability

Scheduled Artists

Additional Questions

Property

Form

Coinsurance

Construction

Additional Interest

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