New Location Application For Pigment and Skin Insurance Program | Exclusive Tattoo Artist Insurance Program

"*" indicates required fields

Step 1 of 4

Business Name (DBA)*

The Business Name (not the Formal Entity Name)

Owner Name*

First Last

Additional Owner Names

Business Formal Entity*

(Full legal business name. Example Tattoo the Zoo, LLC)

Email*

Where you can receive sensitive information

Enter Email Confirm Email

Mobile Phone*

For urgent matters only.

Reason for Submitting Location Application*

Adding a Leased Location, Keeping Existing

Moving to a New Location, Moving out of Existing

Purchasing the Entire Building, I lease the studio within it

I have Multiple Locations I need to Submit for Quote or Renewal

OLD Location Address*

Street Address Address Line 2 City State Zipcode

Location Address*

New or Additional Location

Street Address Address Line 2 City State Zipcode

What Date will you be Moved out of the Old Location?*

Keys handed back and not responsible for the leased space any longer.

MM slash DD slash YYYY

Mailing Address*

All mail for this location will go to this address.

Street Address Address Line 2 City State Zipcode

What will be the Business Location(s) Situation?*

I lease a space/studio. Lease is in my name

Booth, I pay a flat amount each month

1099, Commission Split

Room Share Agreement

I'm 100% booth rental with a flat fee

Health Dept. approved "At Home Studio"

I lease multiple studio locations

W2 Employee, I need my own insurance

I own the Building and Lease it to my Studio

I own the Building

Do you have W-2 Employees?*

Yes

I am considering it

Who Receives W-2 Payroll?*

Clerical (Only)

Front Desk, Clerical, Cleaning and Supply Runs

Tattoo Artist(s)

Piercer(s)

PMU Technician(s)

Hair and Makeup Professional(s)

Esthetician(s)

Total Annual Payroll*

Approximate, in the next 12 Months.

Primary Services offered at this Location*

Check all that apply

I DO NOT offer these Primary Services

Traditional Tattooing

Piercing and Body Mods

Pigment Removal, Non Laser

Permanent Makeup using a machine

Microblading, NO Machine

Scalp Micropigmentation

Camouflage*

Microneedling, Microchanneling (ProCell)

Estimated Revenue, from Move In Date to Policy Expiration*

This is Gross Revenue that you would report to the IRS. Only for the "Act of", (the actual Service offered) Do NOT include 1099 Commission or Tips that they keep, or revenue from Merch or Retail sales. Please ask your agent for clarification.

Offer any Additional Services?*

Please select all services you currently offer or are considering in the future.

I DO NOT offer additional services

Lash Extensions or Tinting

Esthetician Work, Dermaplaning, Massage, Waxing

Traditional Makeup, Hair, FX Makeup, Nails

Injections, PRP, Fillers, Botox

Laser Technician

Electrolysis

Plasma / Fibroblast

Spray Tanning

Hyaluron Pen / Pressurized Injectables

Teeth Whitening

Medical Director

Estimated Revenue for Additional Services, from Move In Date to Policy Expiration*

Do you sell Retail, Merch, Supplies?*

Yes

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Estimated annual revenue from retail, from Move In Date to Policy Expiration

Estimate revenue to the end of the policy term. ONLY the revenue of retail goods that you sell.

Estimated annual revenue from retail, from Move In Date to Policy Expiration*

Estimate revenue to the end of the policy term. ONLY the revenue of retail goods that you sell.

Training or Instruction?

Yes

I'm considering it

Types of Training or Instruction*

None of These

Fundamental PMU Training

Tattoo Apprenticeship

PMU Apprenticeship

Lash Extension Training

Bloodborne Pathogen Training

First Aid

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Estimated Revenue for Instruction, from Move In Date to Policy Expiration

Estimated Revenue for Instruction, from Move In Date to Policy Expiration*

Business Property / Contents

Do you want coverage for contents at your NEW Business Location?*

Decor, Art, Furniture, Antiques, Reference Material, Merchandise, and Retail Stock In the case of Fire, Vandalism, Theft?

YES, I lease a location and I want coverage for contents, Income and Tenant Improvements

NO, I only want General and Professional Liability at this time

YES, But I have less than $10,000 of contents

I understand and agree that I when I select "Liability Only" it is General and Professional Liability for my services, and NOT replacement coverage for my business contents, supplies, machines, income, papers and records etc.*

Yes, I agree

Do you own the building? Do you need coverage for it?*

Yes

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What is the Current Insurable Value of the building?

The lender will tell you this amount

What is the Current Insurable Value of the building?*

Please verify this amount with the lender.

Have you made any "Tenant Improvements"?*

This includes the floors, lighting, molding, paint, cabinetry, etc. How you improved the space when you moved in.

Yes, I have made improvements

No, Decorated only, moved in "as is"

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Total value of Tenant Improvements

To Date, what is the cost of the Improvements YOU have made to your space? We want to put it back the way it was after a loss such as fire, smoke damage etc.

Total Value of Tenant Improvements*

What is the cost of the Tenant Improvements made to your space? Improvements like lighting, moulding, temp walls and cabinets/counters.

Do you need Tenant Glass Coverage?

If you are responsible for the glass breakage or damage, select yes. Glass is not automatically covered; it must be added.

Yes, I am responsible for damages

No, my landlord covers the cost if broken, or I do not need this coverage

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Total Value of Contents / Business Property / Replacement Value

How much money would you need to replace your Furniture, Art, Computers, iPads, supplies, stock, merch, appliances, etc? It's okay to overestimate here.

Total Value of Contents / Business Personal Property*

Our policy uses Replacement Value. How much would you need to replace your contents if there was a loss?

Do you want to add Business Income?*

In the event of a Physical Loss, you cannot work from the location 72 hours or more.

Yes

I need help deciding

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Business Income Coverage

How much income would you need, EACH month for 3 months if your workspace was physically damaged and you could not work/generate an income?

Business Income Coverage*

The amount entered would be divided into three months.

Do you want Coverage for Equipment and Supplies taken "off site"?*

Conventions, Education, Guest Spotting, etc.

Yes

Value at any given time of Off-Site Equipment*

Square footage of your new location?*

Security features. (Check all that apply)*

Theft coverage may be included, but it is subject to a working central alarm system that's operational, notifies the 1st Responders and active at the time of loss.

None

Smoke Detector

Central Station Alarm (ADT etc)

Video System, Notifies the 1st Responders

Interior Fire Spinklers

Roll Down or Cage on Door & Windows

Fire Extinguisher

Deadbolts on all doors

Other

Name of Central Alarm Company

Is your location (building) more than 20 Years Old?*

NOTE - Special Form coverage may not be available if your property manager or building owner has not performed updates and inspections in the last 20 years.

Yes

I don't know

Year Built*

Number of stories of the building*

Construction Type*

Roof Type*

Within 20 miles of an Eastern Coastline?*

NOTE! Wind and Storm Coverage may be Excluded in your area. Please ask your licensed agent for clarification.

Yes

When were the last updates performed to the Roof, HVAC, Plumbing and Electrical?*

Please ask the Property Manager or Landlord if you aren't sure, this information is required to obtain Property Coverage.

See Below

Not Applicable

I need to get this information

Roof*

Approximate Year

Plumbing*

Approximate Year

Electrical*

Approximate Year

HVAC*

Approximate Year

Added Coverage Options

Add Sexual Abuse Misconduct Coverage for $200 per year?*

$200,000 Sub Limit

Yes

Add Assault and Battery Coverage for $200 per year?*

$100,000 Per Claim $200,000 Aggregate Limit

Yes

Add Communicable Disease Coverage for $150 per year?*

$100,000 Sub Limit

Yes

Add Cyber Liability / Data Breach Coverage for $50 per year?*

$25,000 Sub Limit

Yes

Raise the Professional Liability Limit to 1M for $350 per year?*

$1,000,000 Professional Liability Limit (from the included $500,000)

Yes

Do you want Terrorism coverage ?*

$ 150.00 to $250.00 Additional Cost, per year. Only certified acts are eligible for property coverage. A certified terrorism event must be deemed/ classified by the Secretary of the Treasury, Secretary of State, or the Attorney General.

Yes

Does staff use their own cars for bank / supply / food runs?*

Yes

Do you want coverage in case they have an accident in their vehicle?*

Business owners are responsible for damages if a crew member gets in an accident while running errands.

Yes

Do you Require an Additional Insured Certificate of Insurance?

Additional Insured Endorsement

Loss Payee Endorsement

Primary Wording Endorsement

Waiver of Subrogation Endorsement

No, I do not need this

Full Name of Certificate Holder*

Landlord, Building Owner, Property Manager or Lender

Certificate Holder Email

Full Address of Certificate Holder

Landlord, Building Owner, Property Manager or Lender

Street Address Address Line 2 City State ZIP Code

Comment Section

Please provide information and if there are Insurance Requirements, upload them for your agent.

Document or Lease Uploader

Provide documents to the agent for review. Okay to send screenshots.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 12 MB.

The above information is accurate, true to my knowledge.*

I affirm and certify that all the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void and will be cause for cancellation, whenever discovered.

Yes

Consent*

Like most insurance agencies, we use use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance, set you up for monthly payments (if chosen). New or updated information may be used to calculate your premium.

I Agree

Phone

This field is for validation purposes and should be left unchanged.

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