InkShopGuard Proposal Request - Sandstone Header Image

InkShopGuard Proposal Request

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Thank you for your interest in InkShopGuard. Please fill out the form below completely so we can provide you an accurate proposal.

Please note that there are certain subjectivities prior to binding, and coverage cannot be bound via this proposal submission page.

Applicant Information

Contact Name*
Business Mailing Address*
Insurance Status*
How soon do you need coverage?*
When would you like your coverage to begin?*
Location of operations to be insured*
Do you own or rent your building?*
Do you lease space to others?*

Property Information

Construction Type*
If unknown enter closest approximation
If unknown enter closest approximation
Sprinklers*
Fire Alarms*

Please provide approximate year of last update. If unknown, the year built will be used.

Does the building have (either) Knob and Tube or unremediated Aluminum Wiring?*
Is the property a standalone building or part of a strip center*
Do you have 24-hour video cameras?*
Do they have night vision?*
Do you have a central control burglar alarm?*

Shop Information

What services do you offer at your shop? *
Is your shop licensed by the state? *
State License Expiration Date*
Are you a member of a State or National Tattoo or Body Piercing Association?*
Are you in compliance with all city, county and/or state ordinances? *

Please list annual sales and % of the operations

Tattoo and/or Piercing services

$
Dollar amount

Barbershop services

$
Dollar amount

Jewelry sales

$
Dollar amount

Total Sales and % of Operation

$
Licensing for each artist/operator will be collected prior to initiating coverage

Please provide the following information for employee/artist 1

Please provide the following information for employee/artist 2

Please provide the following information for employee/artist 3

Please provide the following information for employee/artist 4

Please provide the following information for employee/artist 5

Please provide the following information for employee/artist 6

Please provide the following information for employee/artist 7

Please provide the following information for employee/artist 8

Please provide the following information for employee/artist 9

Please provide the following information for employees/artists10+

Please upload a list of artist/operator names, years of experience, type of employee (owner, partner, employee, independent contractor), and type of service (tattoo, piercing, hair - note full time and part time).

File Upload 10+*
No File Chosen
File uploads may not work on some mobile devices.

Shop Information Continued

Do you follow a screening process including background checks on staff?*
Do you validate the age of all clients?*
Do you require waivers on all of your clients and maintain copies on file?*
Do you employ apprentices?*
If yes, please attached a detailed description of the training program.
Are any artists independent contractors/leased employees?*
Are Certificates of Insurance obtained?*
Do you wish to place coverage for independent contractors or leased employees?*
Is the shop named as an additional insured on the contractors’ policy?*
Do you have a documented apprentice program?*
Have all artists had formal instruction for their area of expertise?*
Are there written sterilization, sanitation and safety standards?*
Do all artists use a new pair of gloves with each procedure?*
Do you have Blood Borne Pathogen Training?*
Are you contracted with a bio waste disposal firm?*
Are sharp waste containers used in your studio?*
Do you use a client information/prescreening form for all clients?*
Note: A copy of this form will be collected prior to initiating coverage
Does this form include medical history?*
Does this form include a hold harmless clause?*
Does this form include an informed consent clause?*
Do you videotape procedures for documentation procedures?*
Do you use a release and aftercare form for all clients?*
Note: A copy of this form will be collected prior to initiating coverage
Do you schedule a follow up appointment after the procedure?*
Do you have hot and cold running water on site?*
Are there any animals on the premises?*
Are there any firearms on the premises?*
Assault and Battery Exclusion applicable if weapon on premises
Is there any type of entertainment on the premises?*
Do you have a procedure for handling intoxicated persons?*
Do you allow intoxicated persons to have tattoos or piercings?*
Do you manufacture or sell any food, beverage, supplement or vitamin under your own label?*
Are any operations performed away from the shop premises?*

Tattoo Operations

Do you use an autoclave? *
Do you use disposable needles?*
Do you ever re-use needles? *
Are all pigments from U.S. manufacturers? *
Are pigments disposed of after each use? *
Do you or any of your employees or independent contractors provide any of the following procedures? (check all that apply)
Do you do any "Areola Pigmentation"?*
Do you do any tattoing of the eyeball?*
Do you do any type of branding or scarification services?*
Do you offer micro-needling services?*
Do you perform tattoos on minors?*
Is tattooing minors prohibited by your state regulations?*
Do you ever tattoo minor’s genitalia?*
Do you always obtain written consent from a parent or guardian?*
Note: A copy of this form will be collected prior to initiating coverage.

Piercing Operations

Please indicate which body parts piercings are performed on:*
Do you use a piercing gun? *
Do you have a private piercing room?*
Do you sterilize needles with each individual piercing?*
Do you sterilize equipment and materials prior to use?*
Do you produce or manufacture any type of jewelry?*
Do any apprentices perform clitoris or triangle piercings?*
Do you perform piercings on minors?*
Is piercing minors prohibited by your state regulations?*
Do you ever pierce minor’s genitalia?*
Do you always obtain written consent from a parent or guardian?*
Note: A copy of this form will be collected prior to initiating coverage.

Barbershop Operations

Insurance Information

Ex. Partners, Lending Institutions, etc
Would you like a proposal for Workers Compensation coverage?
$
equipment, furniture, décor, etc.

Additional Insured #1

If additional insured interest is not listed above, please enter here
Address*
Would you like a proposal for Workers Compensation coverage?*

Additional Insured #2

If additional insured interest is not listed above, please enter here
Address*
Would you like a proposal for Workers Compensation coverage?*

Additional Insured #3

If additional insured interest is not listed above, please enter here
Address*
Would you like a proposal for Workers Compensation coverage?*

Additional Insured #4

If additional insured interest is not listed above, please enter here
Address*
Would you like a proposal for Workers Compensation coverage?*

Additional Insured #5

If additional insured interest is not listed above, please enter here
Address*
Would you like a proposal for Workers Compensation coverage?*

For 6 or more insurable interests: Please upload a list of additional insureds including Name, Interest (owner, lending institution, etc.) and Address.

*
No File Chosen
File uploads may not work on some mobile devices.
Would you like a proposal for Workers Compensation coverage?*

Loss History

Are there any past or current assault or battery, or sexual abuse or molestation claims involving the applicant or any employee/independent contractor?*
Has anyone ever claimed to have contracted HIV, Herpes, or AIDS from you?*
Are there any past or current claims or pending allegations for alleged malpractice, error or mistake involving the applicant or any employee/independent contractor?*
During the past three years, has any company cancelled, declined or refused you for similar insurance?*
Have you or anyone with a financial interest in the property been convicted of arson, fraud, or other crime related to loss of property owned now or during the past five years?*
Have there been any gaps in coverage in the past three years? *

Claim/Loss #1

Date of Loss*
$
$
Is the Claim Status Open or Closed?*

Claim/Loss #2

Date of Loss*
$
$
Is the Claim Status Open or Closed?*

Claim/Loss #3

Date of Loss*
$
$
Is the Claim Status Open or Closed?*

Claim/Loss #4

Date of Loss*
$
$
Is the Claim Status Open or Closed?*

Claims/Losses 5+

Please upload a list of losses including Date, Amount Paid, Description of Loss, Amount Reserved and whether the claim is Open or Closed.*
No File Chosen
File uploads may not work on some mobile devices.

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially 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 such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL,
KS, LA, ME, MD, MN, NE, NY, OH, OK, OR, RI, TN, VA, VT or WA.)

I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)

Completed by:*
Acceptance*
By accepting this form electronically, I am acknowledging that I have read, understood, and agree to the terms of the Agreement.
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ACH / EFT PAYMENT

Please Note!
Returned ACH Payments will incur a $35.00 Fee.
Billing Address Country *
Please specify your billing address country
United States - Billing Address For ACH / EFT*
Outside United States - Billing Address For ACH / EFT*
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