Are any of the building procedures conducted?
Please Complete This Section for ALL Employees & Sub-Contractors who perform Injectable services:
** PLEASE CHECK APPLICABLE SERVICES
** PLEASE ADVISE WHO PERFOMS SERVICE (D = doctor & N = Nurse)
** N/A means that we cannot offer this service
PLEASE COMPLETE ALL QUESTIONS
IF YOU REQUIRE ADDITIONAL SPACE, PLEASE ADD ADDITIONAL PAGES AS NECESSARY
Please advise IF and HOW you provide the following operations (Please check all lines of operations):
**Please provide all operators who provide laser treatment or cellulite treatment and their experience:
Please answer all questions:
LIABILITY INFORMATION – Limits will be the same as the main operations that you have provided.
(Premium advantages if each salon location is listed as a Smart Tan Member – Ask us if salons are not members)
Please complete this section for all Massage Therapists on Staff:
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 determination of insurability. The
under-signed, therefore, warrants that the information contained herein is true and accurate to the best of his / her knowledge, information, and belief. This
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. 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. For purposes of the Insurance Companies Act (Canada), any
document would be issued in the course of Lloyd’s Underwriters’ insurance business in Canada.
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