Spa Insurance Property & Liability Application

Salon/Spa Application

Please complete this application in its entirety, as the responses given are material to the provision of terms. There is space for more details in the Additional Information Section at the end of the application. Applications Requests Only for Alberta, BC and Ontario**
Operating Company Full Legal Name:*
Mailing Address:*

Street Address Line 2

City Province

Postal Code
Name*

First Name Last Name
Company Website:
Email*
example@example.com
Phone:*
Please enter a valid phone number.

Section 1: About Your Organization
What year was your organization established:*

MonthDay Year
Date
Form of Business:*

IndividualPartnershipCorporationOther
Please Provide Gross Revenue: (If First Year - Please Provide Anticipated)*
Has your business named changed in the past 5 years?*

YesNo
Please provide details:
Do you expect any changes in your operations in the next 12 months?*

YesNo
Please provide details:

	Percentage (%)
Body Wraps, Ears/Nose Piercing, Exfoliation, Eyebrow and Eyelash Tinting, Eyelash Extensions, Facials, Gel and Acrylic Nails, Hairdressing and Extensions, Manicures and Pedicures, Microdermabrasion, Non-Permanent Make Up, Paraffin, Sugaring, Threading, Waxing

	Percentage (%)
Acupuncture, Dry Needling Acupressure, Reflexology, Aromatherapy, Brow Lamination, Cupping, Electrolysis, Electric Epilation, Energy Healing (e.g., Reiki), Energy Therapies (e.g., Therapeutic Touch, Body Tapping), Henna Tattooing, Hypnotherapy (excluding past life regression), Ionization Detoxification, Iridology, LED Light Therapy, Electromagnetic Therapies, Radionics, Mediation, Biofeedback, Movement Therapies, Fitness (e.g., Alexander Technique, Feldenkrais, Tai Chi, Yoga), Moxibustion, Nutrition (Canadian Food Guide)

	Percentage (%)
Acid Peels < 31% concentration, Carboxytherapy, Colonic Irrigation, Dermabrasion, Dermaplaning, Ear Irrigation, Endermologie, Hydrotherapy, (e.g., Rolfing, Onsen), Micro Needling
Massage Therapy, Shiatsu, Massage with Movement /Alignment (e.g. Rolfing, Onsen)

	Percentage (%)
Acid Peels greater than 31% and less than 61% concentration, Cellulite Reduction (SculpSure via Lapex, Zerona, VaserShape or similar device), Cellulite Treatment (RF, Ultrasound), Coolsculpting Ear and Body Candling, Laser Acupuncture, Low-Level Laser Therapy (LLLT, Cold Laser), Mole and Skin Tag Removal, Myofascial Release Therapy, Radio Frequency (RF) Skin Tightening, Radio Frequency (RF) Skin Tightening

	Percentage (%)
Ablative Erbium Laser, Cellfina, High Intensity Focused Ultrasound, Injection Services, Semi-Permanent Make Up, Microblading, Micropigmentation, Semi-Permanent Make Up, Microblading, Micropigmentation
Laser/IPL/EPL/LHE
Vaginal Rejuvenation and Incontinence Treatment
Injections
Injectable Minerals/Vitamins, IV Therapy with Minerals / Vitamins
Platelet Rich Plasma
Teeth Whitening
Tanning

	Percentage (%) of PRP services
Cellulite Reduction
Erectile Dysfunction
Hair Restoration
Neck Rejuvenation
PRP with Injectable Products
Vaginal Rejuvenation (O Shot)
Vampire Facial
Other, please indicate:

Section 6: Staffing

Please provide details of all individuals providing services:

	Name	Professional Designations	FT / PT / Contract	Years Experience	Services Provided	Carries Own Insurance
1
2
3
4
5
6
7
8
9
10

You can also provide your own Employee List if you wish:

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Section 7: Products
Do you sell any products?*

YesNo
Please indicate how much revenue comes from the sale of these products:
Are any of these sold outside of Canada?*

YesNo
Please provide details:
Are any of these products sold under your organization’s name or brand(s)?*

YesNo
Please provide details:
Please indicate what type of products you sell?*

Section 8: Claims History
Have you ever had a claim against your organization's insurance policies?*

YesNo

Are you aware of any claims that were made against any of your staff or contractors in the past 5 years?*

YesNo
Please provide details:
Are you aware of any incidents or circumstances that could potentially give rise to a claim?*

YesNo
Please provide details:

Section 9: Prior Insurance
Have you ever been declined coverage, cancelled or non-renewed for insurance requested in this application?*

YesNo
Please provide details:
Do you currently have insurance in place?*

YesNo
Date of your renewal:

MonthDay Year
Date
Insurance Company Name:
Retroactive Date:

MonthDay Year
The retroactive date is typically based on the date from which the insured has had (uninterrupted) professional liability coverage. Retroactive dates often pre-date the policy's inception, potentially providing coverage for claims that arise from acts or omissions taking place prior to the policy's inception date
Copy of policy if you would like our team to review your current coverages

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Section 10: Requested Insurance Coverage
General Liability & Professional Liability Request*

2,000,0003,000,0005,000,00010,000,000
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 an 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 the determination of insurability. The undersigned, 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. The 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 Acumen Insurance 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
Name (please print):*
Title:*
Date*

MonthDay Year
Date
Signature*

Clear
Additonal Information Section
Please use this space to provide any additional information from the questions above, from the addenda or anything you feel is material to your operations:
Should be Empty:

	Laser	IPL
Acne
Cosmetic Re-pigmentation
Cellulite Treatment
Endovenous Ablation
Hair Removal
Incontinence
Treatment
Leg Veins
Pigmented Lesions
Psoriasis, Vitiligo
Tattoo Removal
Vaginal Rejuvenation
Vascular Lesions

	Make	Model	Age	Leased/Owned	Replacement Value	Date of Last Maintenance
1
2
3
4
5
6
7
8
9

	Age (Years)	Leased/Owned	Number of Units	Type of Timer	Date of Last Maintenance
Beds
Booths
Spray Booths
Air Brush

Salon/Spa Application

Section 1: About Your Organization

Section 2: Operations

Section 3: Application Addenda

Injection Services, Platelet-Rich Plasma (PRP)

Laser (IPL, EPL, LHE) Services

Semi-Permanent Make Up, Microblading, Micropigmentation

Tanning Services

Teeth Whitening Services

Property Coverage

Section 4: Location Details

Section 5: Crime Coverage

Section 6: Staffing

Section 7: Products

Section 8: Claims History

Section 9: Prior Insurance

Section 10: Requested Insurance Coverage

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

PRIVACY CLAUSE

PLEASE NOTE:

	Injectable Product	Percentage (%) of volume of sales
1
2
3
4

	Date of loss	Amount paid or help in reserve	Description of allegation
1
2
3
4