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The Lash Lounge Insurance Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Applicant Information
First Name
Required
Last Name
Required
Name of Corporation or LLC
Required
Name of Business (your "dba" or "t/a" name)
Required
Name of business owner(s)
Required
Mailing Address
Required
City
Required
State
Required
ZIP / Postal Code
Required
County
Required
Primary Phone Number
Required
Fax
Required
Website
Required
E-Mail Address
Required
FEIN (Federal Employer Id Number) or Social Security Number
Required
Type of Ownership
Required
How long have you owned this business?
Required
List any professional associations in which you are a member
Optional
Physical Address of Store
Required
City, State. ZIP Code
Optional
Square Footage of Physical Location
Required
Does Physical Location Have a Monitored Alarm?
Required

Insurance Information
Limits of Liability
Required
*please note this limit is only available for tattoo and body piercing
Deductibles
Required
Note: Optional deductibles not available in all states. NOTE: a minimum deductible of $100 shall apply to micropigmentation and body piercing policies Note: A minimum $250 shall apply to tattoo policies
Previous Insurance Carrier
Required
Policy Number
Required
Policy Period
Required
Claims Made or Occurrence Form
Required
If previous policy had claims made, attach a copy of the policy and provide retroactive date
Optional
Has any previous carrier cancelled or not renewed a policy (not required in Missouri)?
Required

If yes, please provide details
Optional
Professional Services Information
Check the professional services that you perform and for which you desire coverage under this policy
Optional










If other was checked, please describe
Optional
NOTE: Any professional services for which you do not list below will not be covered under this policy. NOTE: Checking any professional service does not obligate us to insure it
List the number of united for each type of equipment that are used in your business and for which you desire coverage under this policy
Tanning Beds/Booths/Units
Optional
Hydrotherapy Tubs/Hydrotherapy Tables/Showers
Optional
Exercise Equipment
Optional
Indicate the number of employees, independent contractors and students performing the professional services shown below
Aestheticians
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Body Piercing
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Electrologists
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Hair/Nails/Cosmetics
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Massage Therapists
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Micropigmentation
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Micorpigmentation Instructors
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Personal Trainers/Yoga Instructors
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Tattoo
# of Employees
Optional
# of Independent Contractors
Optional
# of Students
Optional
Total
# of Employees
Required
# of Independent Contractors
Required
# of Students
Required
Are all technicians licensed, if required by law?
Required

Are any employees or independent contractors medical doctors?
Required

If yes, do they provide treatments/services to customers?
Optional

If yes, attach proof od medical malpractice insurance coverage for doctors
Optional
List schools you attended and degrees or certifications received
Required
(NOTE: Micropigmentation technicians must attach a copy of training certificate or diploma)
Optional
If you checked "Body Piercing", "Micropigmentation/Cosmetic Tattooing" or "Tattoo" earlier, please answer the following:
Do you always obtain a medical history for every client?
Optional

If yes, attach a copy (Note: obtaining a medical history is required by policy)
Optional
Do you always supply a patient/customers with aftercare information?
Optional

If yes, attach a copy (Note: distribution of aftercare information is required by policy)
Optional
Do you always obtain a signed consent or release form?
Optional

If yes, attach a copy (Note: use of consent/release form is required by policy)
Optional
Do you use piercing guns?
Optional

If yes, are they used only on earlobes?
Optional

Describe your method of sterilization for your equipment (including needles) and both used and unused jewelry
Optional
Do you pierce or tattoo minors?
Optional

If yes, describe your policy for piercing or tattooing minors
Optional
If you checked "Body Massage" earlier, please answer the following
Do you provide massage services to minors?
Optional

If yes, describe your policy for massaging minors
Optional
Do you obtain criminal background checks on all massage therapists
Optional

Do you provide chemical/acid peel services?
Optional

If yes, do you use any of the following:
Trichloroacetic acid (TCA) preparations with concentrations over 20%
Optional
AHA preparations with concentrations over 30% with PH lower than 3.0?
Optional
Jessner's solution preparations with concentrations over 14%?
Optional
Any medical grade peels?
Optional
Do you perform sclerotherapy, treat telangiectasias, or perform any other services to minimize the appearance of veins?
Optional

If yes, describe services
Optional
Do you provide any services intended to remove skin tags, warts, moles or other growths?
Optional

If yes, describe services
Optional
Loss Information
Have there been any claims reported against the applicant in the last five years?
Required

If yes, attach a complete description including name of claimant, date of claim, nature of injury and amounts paid
Optional
Any there any pending claims against this applicant?
Required

If yes, attach a complete description including name of claimant, date of claim, nature of injury and amounts on reserve
Optional
Upon communication with all of your partners, employees, independent contractors and students, are you aware of any act, error or omission that might give rise to a claim under the proposed policy?
Required

If yes, attach a complete description including name of potential claimant, description and date of act, error or omission and nature of injury
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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5712 Colleyville Blvd., Suite 240 | Colleyville, TX 76034 | 855.546.2467 Powered by Insurance Website Builder