Insurance Application

Insurance application for the Pigment and Skin Insurance Program.

"*" indicates required fields

Business Name (DBA)*

The Business Name (not the Formal Entity Name)

Type of Entity*

The type of formal business entity.

The Formal Entity Name*

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

Your Name*

First Last

Additional Owners (if Any)

Is this a Renewal Application?*

Yes

Returning Client

Email*

Where you can receive private information

Enter Email Confirm Email

Mobile Phone*

Business Phone*

May we text you?*

Consent is not required as a condition of purchase. Message frequency will vary. Message and data rates may apply. Reply HELP for help or STOP to cancel. View our Privacy Policy.

YES! Absolutely!

NO! Please, no.

Old School, no thanks!

Instagram Handle*

Facebook Handle*

Website (Not Required)

How would you describe your business?*

Traditional Tattoo & Piercing Shop

Traditional Tattoo Shop, Tattooing Only

Independent 1099 Tattoo Artist or Piercer

Professional Piercing Studio, Piercing Only

Permanent Makeup, Paramedical, SMP Services

Beauty Only - Esthetician, Dermaplaning, Hair, Nails, Massage Etc.

Apprentice, I need my own coverage

FEIN

Not required, but we may need it in the future

Your Birthdate

So we can celebrate with you!

YYYY

Are you currently insured with another company?

Yes, I am shopping for my future renewal

It Expired

I am not sure

Location Address*

Let your agent know if you lease multiple locations.

Physical Street Physical City Physical State Physical Zip

Mailing Address*

Same as Location Address

Mailing Street Mailing City Mailing State Mailing Zip

Do you work at multiple locations WITH a lease agreement?

Only select yes IF there is a Signed Lease in your name. Our policy follows you throughout America automatically.

YES

What is your current 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

I am an apprentice

Room Share Agreement

Health Dept. approved "At Home Studio"

W2 Employee, I need my own insurance

I own the Building and Lease it to my Studio

Do you have W-2 Employees?*

Yes

I am considering this

Who Receives W-2 Payroll?

Clerical (Only)

Front Counter, Clerical and also Cleaning and Supply Runs

Tattoo Artist(s)

Piercers(s)

PMU Tech(s)

Esthetician(s)

Total Annual Payroll*

Approximate, in the next 12 Months.

Primary Services Offered*

Check all that apply that you / yourself are performing. Include direct W2's or 1099's working within your business. Do not include services offered by room or booth renters (separate entities).

I DO NOT offer these Primary Services

Traditional Tattooing

Piercing, Body Mods

Pigment Removal, Non Laser

Paramedical Services

Permanent Makeup using a machine

Microblading, NO Machine

Scalp Micropigmentation

Camouflage*

Microchanneling, ProCell

Microneedling

Tiny Tattoos

Areola Tattooing

If you offer Tiny Tattoos, How many hours of training? Were you already a PMU artist?*

We do not offer coverage to anyone without proper training for Tiny Tattoos. Please seek a extended apprenticeship or training.

Have you had at least 100 hours of Fundamental Training?*

We do not offer coverage without a minimum of 100 hours of fundamental training. We require you to present training credentials.

Estimated Gross Annual Revenue for Primary Services*

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 artists keep, or revenue from Merch or Retail sales. Please ask your agent for clarification.

Offer Additional Services?*

Check all that apply that you / yourself are performing. Include direct W2's or 1099's working within your business. Do not include services offered by room or booth renters (separate entities).

I DO NOT offer any of these services

Lash Extensions or Tinting

Esthetician Work

Peels

Dermaplaning

Waxing

Massage

Traditional Makeup, FX Makeup

Hair Services

Nails

Permanent Jewelry

Injections, PRP, Fillers, Botox

Laser Technician

Electrolysis

Plasma / Fibroblast

Spray Tanning

Hyaluron Pen

Teeth Whitening

Medical Director

Cryo

Tooth Gems

Estimated Gross Annual Revenue for Additional Services*

Do you sell Retail, Merch, Supplies?*

Yes

Estimated Gross Annual Revenue for Retail Goods*

This is Gross Revenue that you would report to the IRS. Liability coverage for retail sold goods in case of suit against you for damages from product sold. We do not cover manufactured, relabeled or handmade products. Ask your agent for a product liability policy quote.

Do you Offer Training or Instruction?

Yes

Types of Training or Instruction*

None of These

Fundamental PMU Training

Tattoo Apprenticeship

PMU Apprenticeship

Lash Extension Training

Bloodborne Pathogen Training

First Aid

Estimated Annual Revenue for Instruction Services*

This is the Gross Revenue you would report to the IRS.

Training Details

Could you please share more information about what you're teaching and any structural information you have? We want to make sure that you are covered properly.

Our GL Limit is $2,000,000 Agg /$1,000,000 per Occ. Want to raise it to $3,000,000 /$2,000,000 for an Additional $750.00 per year?*

Yes

We provide $500,000 in Professional Liability. Would you like to raise it to $1,000,000 for an Additional $350 per year?*

Yes

Does your Landlord or Property Manager Require a Certificate of Insurance that must have a Waiver of Subrogation?*

If you are unsure, please upload that page of your lease at the end of this application, or ask your agent.

Yes

I am not sure

Does your Landlord or Property Manager Require a Certificate of Insurance that must have Primary Wording?*

If you are unsure, please upload that page of your lease at the end of this application, or ask your agent.

Yes

I am not sure

Do you want coverage for contents at your 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 to cover my business contents

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

If you are within an Eastern Coastal or Gulf Coastal State, do you want coverage for wind if available?*

The carrier issued recent underwriting changes. Please speak with your agent about coverage for property damage caused by gusty events in your State. Wind is not offered in all States.

Yes, I want Wind Coverage.

No, I DO NOT want Wind Coverage.

I am not in an Eastern or Gulf Coastal State.

I understand and agree that I when I select "Liability Only" it is General and Professional Liability for my services, and NOT coverage for my business contents, furniture, tenant glass, stock, merchandise, papers, records etc.*

Yes, I agree

Do you own the building?*

Do you need coverage for the entire building?

Yes

What is the Current Insurable Value of the building?*

Have you made any "Tenant Improvements"?*

This includes the floors, lighting, molding, cabinetry etc. anything "attached" to your studio.

Yes, I have made improvements

No, Decorated only, moved in "as is"

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.

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

Total value of Contents / Business Property*

Our Property Coverage is Replacement Value. How much would you need to replace Furniture, Art, Computers, iPads, supplies, stock, merch, appliances, etc?

Do you want Business Income Coverage?*

This amount is divided by three months for a physical loss longer than 72 hours, that prevents you from performing services. Proof of lost income is required.

Yes

Business Income Amount - Per Month*

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?

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

Conventions, Education, Guest Spotting, etc. (Theft and Damage while away from the studio)

Yes

Value at any given time of Off-Site Equipment*

Maximum Limit of $20,000

Square footage of your leased area*

Security features. (Check all that apply)*

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

None

Central Station Alarm (ADT etc)

Video System, Notifies the 1st Responders

Roll Down or Cage on Door & Windows

Smoke Detector

Fire Extinguisher

Deadbolts on all doors

Interior Fire Spinklers

Other

Name of Security/Central Alarm Company

Year Building was Built*

Number of stories of the building*

Describe your Business Location within the Building*

**Street level means your business provides goods and services adjacent to, visible from, and accessible from the sidewalk.

Street Level**

Second Floor

Third Floor and Higher

Construction Type*

Roof Type*

Has the Prop Manager performed Inspections or updates to your leased location within the last 20 years?*

Please enter the Year each was Updated OR Inspected. Please ask the Property Manager or Landlord if you aren't sure, this information is Critical for the best Property Coverage available.

YES, See Below

UNSURE, I need to ask the Landlord

Roof*

Approximate Year

Plumbing*

Approximate Year

Electrical*

Approximate Year

HVAC*

Approximate Year

Are you concerned about Discharge From Sewer, Drain or Sump damage?*

Yes

Do you have Fine Art inside your location?

Yes

Are you concerned about Employee theft?

Yes

Do you offer beer or wine?*

Yes

Do you comply with all City, County, Health and State Ordinances?*

This is a condition of our policy

Yes

Have you ever had a Health Department Violation?*

Yes

Stay current on Bloodborne Pathogen education?*

This is a condition of our policy

Yes

Do you obtain a signed release form for each client?*

This is a condition of our policy

Yes

How long do you keep signed forms on file?*

We encourage cyber safety precautions for digital release forms and privacy precautions with paper forms.

up to 1 Year

1-5 Years

5-10 years, I want them in case I get sued

Do you check, photocopy and keep on file the client's ID?*

Per your state and county health dept guidelines. This is mandatory in California.

Yes

Do you provide "After Care Info" after each procedure?*

This is a condition of our policy

Yes

Are you prepared to handle fainting or nauseated patrons?*

Yes

Are you 100% single use?*

Yes

Do you always use barriers and cord wraps?*

This is a condition of our policy

Yes

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

$25,000 Sub Limit (Breach of your Clients Data)

Yes

Add Communicable Disease Coverage for $150 per year?*

$100,000 Sub Limit. Ideal for Tattooers, Piercers, Microbladers or Machine work of any type.

Yes

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

$200,000 Aggregate Limit This coverage is primarily for studios with exposures to vagrants, near bars or heavy public foot traffic outside it's doors.

Yes

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

$200,000 Sub Limit, Select if you are worried about being accused of touching someone inappropriately or perform areola or genital piercings.

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 can be responsible for damages if someone gets in an accident while running errands.

Yes

Does your Landlord require a higher Premise Damage limit?*

We provide $100,000 automatically.

$300,000

$500,000

$1,000,000

I am not sure, I will upload my lease

Do you want Terrorism coverage?*

Only certified acts are eligible for coverage through TRIA. A certified terrorism event is classified by the Secretary of the Treasury, Secretary of State AND the Attorney General. PLEASE ask your agent to explain this coverage before purchasing.

Yes

Do you want to cover your business items from theft and damage.

Perfect for Booth or Room renters that bring their machines and supplies to and from the space for appointments. Coverage for theft and damage.

No Thank you

$5,000

$10,000

$15,000

$20,000

Do you manufacture, re-label or repackage products to sell under your own name?*

If so, you need a Product Liability policy.

Yes

Please describe the products you make or re-label*

Our Program does NOT include product liability. Agents can help you find coverage with an alternative carrier.

Who Referred you?*

Referral Code:

Have you had a policy cancel for Non Payment in the past 12 months?*

Yes

Have you had any claims or losses in the last 5 years?*

Yes

Please describe your claim and it's outcome

Landlord / Property Manager / Additional Insured Certificate Information

Landlord Additional Insured Certificates are complimentary. Waiver of Subrogation and Primary Wording endorsements are $50.00 Each

Do you Need an Additional Insured Certificate?*

Please provide the most updated information for our records.

No, not currently

Yes, for my Landlord

Yes, it's the same as Last Year (On File)

Yes, with Waiver of Subrogation AND Primary Wording

Yes, with Waiver of Subrogation

Yes, with Primary Wording

I am not sure, I will upload my lease

Want us to email it directly to them?*

Yes, see email below

No, I will provide it to them myself

Landlord Name / Entity Name

Property Manager / Landlord Email*

Your Agent will email the Certificate of Insurance

Property Manager/Landlord Address*

Address to be Listed on Certificate of Insurance. Usually on the Lease Agreement.

Street Address Address Line 2 City State ZIP Code

Comment Section

Anything you want us to know!

Additional Document Uploader

Loss Runs, Other Company Quotes, Claim Documents, Additional Insured Requirements

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 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 renewal premium.

I Agree

Today's Date*

MM slash DD slash YYYY

Phone

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

Business owners get your insurance quote through our program.

Insurance application for the Pigment and Skin Insurance Program.

Landlord / Property Manager / Additional Insured Certificate Information

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