Application for Members of the Joint Canadian Tanning Association Tanning Salon and Beautification Services Application

Transcription

1 Application for Members of the Joint Canadian Tanning Association Tanning Salon and Beautification Services Application All questions must be answered completely. If a question is not applicable, please answer NA. If the answer to a question is None, state None or 0. If more space is required to completely answer a question, please attach a separate sheet of paper and identify the question to which it responds. THE APPLICANT 1. Proposed Named Insured Applicant is: Corporation Partnership Joint Venture Number of Years in Business 2. Mailing Address, including Postal Code 3. Location Address, (if different from the above) 4. Are there Additional Locations? Yes No If yes, please provide complete address for each below: Loc #1 Loc # Name of Contact Person Website Business Tel # Business Fax # Current Insurer Loc #3 Name Policy # Expiry Date Premium JCTA August of 11

2 THE PROPERTY To be completed for each Location to be insured. Location Address: 1 Describe your Location Strip Plaza Shopping Mall Stand-alone Structure 2 Do you own the Building? Yes No Age # of Storeys 3 Provide the year of latest updates, if over Wiring 25 years / 1983 Plumbing Heating 4 Total Area of Building Total Area of your Facility sq ft sq ft 5 Construction of Walls Concrete Steel Deck Brick Veneer over Wood Wood 6 Construction of Roof Alarm Protection Burglar Alarm Concrete Steel Deck Encased in Concrete Steel Deck Metal Clad Wood Joist Local Central Monitored None Alarm Protection Fire Alarm Local Central Are your Premises sprinklered? Yes No Fire Hydrant within 500 ft JCTA August of 11

3 7. LIMITS OF INSURANCE Co-Insurance, 90% Deductible, $1,000 unless specified otherwise Type of Insurance Limit Required Deductible (If higher than $500 requested) If owned Building Contents /Equipment (Limit must be selected) Misc Equipment Includes Tanning Beds, Stock, Tenants Improvements Etc Please Specify Equipment Other, please list other types of insurance you may require: Co-Insurance, 90% Deductible, $1,000 unless specified otherwise Standard Limit of Type of Insurance Insurance (Automatically Included) Equipment /Stock Off-Site $50,000 Equipment Breakdown Total Combined of Building & Contents/ Equipment Accounts receivable $50,000 Limit (If higher Limit is Required) Deductible (If higher than $500 requested) Valuable Papers $50,000 Business Interruption ALS Actual Loss Sustained Fidelity $25,000 Crime $10,000 Commercial Liability $2,000,000 Tenants Legal Liability $ 1,000,000 Other, please list other types of insurance you may require: JCTA August of 11

4 OPERATIONS OVERVIEW 1 Tanning Equipment information Number of: Beds _ Spray Booths Other, specify Booths Air Brush 2 Number of Staff Full Time Part Time 3 Revenues Tanning Receipts $ Product Receipts $ Beautician: $ Other: $ Other: $ Other: $ 4 Are Health Regulations followed? Yes No 5 Have you ever been cited for violations of any health or safety codes? Yes No If yes, please explain: 6 Is the equipment inspected and cleaned after each use? Yes No 7 Do all clients sign waivers? Yes No 8 Are all Staff Smart Tan Certified? Yes No 9 Do all clients complete a skin analysis Yes No 10 Are all clients required to wear goggles? Yes No 11 Are all clients given tanning instruction? Yes No 12 How is the age of the customer verified? 13 Who sets the amount of time a client is able to tan on each bed? Client Staff 14 Where is the Timer Located, which sets the amount of time a client can tan? Front Desk Bed 15 Are any beds operated by Tokens and or/coins? Yes No If yes, please explain: JCTA August of 11

5 PLEASE ADVISE WHAT SERVICES THE INSURED OFFERS: (Circle the most appropriate answer) Acid/Glycolic Peels (less than 30% solution concentrations) Acid/Glycolic Peels (between 30% to 60% solution concentrations) Acid/Glycolic Peels (greater than 60% solution concentrations) Y or N Y or N Y or N Aqua Massage Beds - # of beds_ Y or N Body Wraps Y or N Body Vibration Weight loss - # of units Y or N Cellulite Treatment Y or N Chiropractors on staff Y or N Cosmetic Acupuncture Y or N Diet / Nutrition Y or N Dry Heat Sauna Beds - # of beds Y or N Eyebrow Tinting Y or N Eyelash Curling & Perming Y or N Electroquagulation Y or N Ear Candling Y or N Facials Y or N Hair Cutting / Coloring Y or N Hydrotherapy Tubs # of units Y or N Hot Tub or Whirl Pool # of units Y or N Infrared Sauna # of units Y or N Ionization Foot Detoxification Y or N Micropigmentation Y or N Makeup - Non-Permanent Y or N Manicure / Pedicure Y or N Does your company use MMA (Methyl Methacrylate) within the Nail Manicure / Pedicure process Y or N Mole Removal by Solution only Y or N Mole Removal Invasive Cutting Y or N Oxygen Bar or Oxygen Services Y or N Piercing -Ears/ Nose Only Y or N Piercings other than Ears / Nose Y or N Physical Therapist on Staff? Y or N Sauna Wet or Dry #of units Y or N Skin Tag Removal - Invasive Cutting Y or N Skin Tag Removal by Solution only Y or N Spray Tanning Handheld Y or N Spray Tanning Booth Y or N Steam Rooms #of units Y or N Stripping Veins Y or N Swimming Pool #of units Y or N If yes, Maximum Depth? feet Tattooing Spray on Y or N Tattooing Henna Y or N Tattooing Body other than Micropigmentation Y or N Toning Beds #of units Y or N Sclerotherapy Y or N Waxing / Sugaring Y or N Wart Removal by Solution only Y or N Wart Removal - Invasive Cutting Y or N Weight Loss by Supplements Y or N Electrolysis Y or N If yes, please complete the Electrolysis Supplementary application on page 5 Massage Y or N If yes, please complete the Massage Supplementary application on page 5 Laser / IPL Treatment Y or N If yes, please complete the Laser / IPL Supplementary application on page 6 & 7 Injectable Services Y or N If yes, please complete the Injectable Supplementary applicationon on page 8 Microdermabrasion Y or N If yes, please complete the Microdermabrasion Supplementary application Other Services Y or N If yes, please list: _ JCTA August of 11

6 ACID PEELS SUPPLEMENTARY APPLICATION 1 Do you sterilize equipment? Yes No 2 Does all staff wear sterilized gloves when performing services? Yes No 3 Do you provide Medium Peels? Yes No 4 Do you provide Deep Peels? Yes No ELECTROLYSIS SUPPLEMENTARY APPLICATION 1 Do you sterilize equipment? Yes No 2 Does all staff wear sterilized gloves when performing services? Yes No 3 Do you use disposable tips for each new client? Yes No Please complete this section for all Massage Therapists on Staff: MASSAGE SUPPLEMENTARY APPLICATION NAME OF MASSAGE THERAPIST TYPE(S) OF MASSAGE THEY PERFORM (please list all) YEARS OF EDUCATION YEARS OF EXPERIENCE ARE YOU AN RMT? YES NO 1 What type(s) of Massage do you perform? (Please list all) _ 2 Do you collect and discuss the client s health information? Yes No 3 How long do you keep clients health information / waivers on file? Years 4 Is a waiver signed, dated and kept on record? Yes No 5 Do you offer massages to infants? Yes No JCTA August of 11

7 LASER SUPPLEMENTARY APPLICATION 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): SERVICE Acne Endovenous Laser Treatment Leg Veins Psoriasis & Vitiligo Skin Resurfacing Cosmetic Re-pigmentation Hair Removal Pigmented Lesions Vascular Lesions Cellulite Treatment PULSE LIGHT/ LASER IPL YES NO YES NO Other (please describe) *Please provide all operators who provide laser treatment or cellulite treatment and their experience: NAME PERSON PROVIDING LASER TREATMENT YEARS OF EDUCATION YEARS EXPERIENCE/ QUALIFICATION ANY PRIOR CLAIMS MADE AGAINST EACH INDIVIDUAL PLEASE GIVE BRIEF DETAILS *Complete this section for all laser/cellulite machines (please list additional hand pieces separately): CURRENT REPLACEMENT COST MAKE MODEL AGE IN CANADIAN $$ JCTA August of 11

8 LASER SUPPLEMENTARY APPLICATION (CONTINUED ) Please answer all questions: 1 Please circle what skin types you provide services on for the laser treatments: As per the Fitzpatrick Scale: Percentage of gross receipts from laser operations % 3 Do you complete a skin patch test prior to laser treatments? Yes No 4 How long do you wait after the patch test to perform laser treatment? 5 Do you wear surgical gloves when providing laser services to clients? Yes No 6 Does your client wear protective eyewear during laser services? Yes No 7 Do you keep copies of all client service records? Yes No 8 How many years is service records kept on file? years 9 Is a waiver signed, dated and kept on record? (please attach a copy) Yes No 10 How many years are waivers kept on file? years 11 Do you explain to the client what steps to take prior to any laser treatment Yes No Please describe 12 Do you explain to the client what steps to take after any laser treatment? Yes No Please describe 13 How often do you calibrate your machines? 14 Do you provide any off-site laser treatments Yes No If yes, list all locations, methods of transporting equipment and frequency of all off-site treatments: JCTA August of 11

9 INJECTABLE SUPPLEMENTAL APPLICATION * Please Complete This Section for ALL Employees & Sub-Contractors who perform Injectable services: # of Full time (F/T) Employees? # of Part time (P/T) Employees? # of Contract People? NAME YEARS OF EDUCATION YEARS OF EXPERIENCE HAVE THEIR OWN INSURANCE FOR THIS SERVICE IS THIS PERSON A DOCTOR IS THIS PERSON A REGISTERED NURSE COVERAGE AVAILABLE ** PLEASE CHECK APPLICABLE SERVICES ** PLEASE ADVISE WHO PERFORMS SERVICE (D = doctor & N = Nurse) ** N/A means that we cannot offer this service Aquamid Artecoll N/A Bio-Alcamid Bioinblue Botox Collegan Cymetra N/A Deep Lines /Kiss/Ultra Deep Dental Blocks Dermadeep Dermalive Dysport Elastence Esthelis Basic/Soft Evolence Evolution Hylaform/Fineline/Plus Hydrafill 1/2/3/Softline/Max IAL System Juvederm 18/24/24hv/30/30hv Juvelift Laresse Matridex Martridur Outline Puragen Puragen Plus Radiesse Restylane Sub Q Restylane/Touch/Perlane/Lipp Reviderm Intra Restylane Vital Sculptra (Newfill) Surgiderm 18/24xp/30 Surgiderm 30xp Surgilift Plus Surgilips Teosyal Global Action /Touch Up Teosyal Meso Vistabel Viscontour Voluma Zyderm 1/2/Zyplast 1. Has any Insurer ever cancelled, restricted or refused to renew your insurance? Yes No If yes, please provide complete details. _ 2. Have you ever been sued or has any claim been made against you arising out of your services? Yes No If yes, please provide complete details. _ * No Coverage is offered for sale and/or distribution of equipment with movable parts. ** No Coverage is offered for manufacturing/mixing/blending of products other than aromatherapy. JCTA August of 11

10 Policy Warranty In order to qualify for this program the following conditions must be met: 1. Tanning beds must be newer than All clients must sign a waiver holding the named business and their employees harmless. Must be kept on file for no less than seven years. (7yrs) 3. All clients prior to using a bulb tanning system for the first time must fully complete and sign a tanning skin analysis. (Must be kept on file for no less than seven years. (7yrs) 4. Signs must be posted within the tanning room and outside the tanning room area noting that eye protection must be worn. 5. Within the client signing contract it must be noted that the client understands that they must wear eye protection. 6. All clients must be given full tanning instruction, a tour of the salon including the use/operation of all equipment. 7. All bulb tanning system timing mechanisms that set the length of time a client is permitted to tan, must be controlled from the front desk. TIMING MECHANISMS CONTROLLED WITHIN THE TANNING ROOM OR LOCATED ON OUTSIDE WALLS WILL NOT QUALIFY FOR THIS PROGRAM. 8. All tanning equipment must be cleaned after every use. 9. Employees must be adequately trained prior to setting any timer mechanisms and must be smart tan certified within 90 days of their date of hire. 10. No prior claims within the past 5 years. 11. The Named business requesting insurance MUST have a combined membership with the JCTA and Smart Tan. NOTE: Non-compliance of conditions 1 thru 11 will effect your insurance coverage: Coverage will not apply to any bodily injury claims provided under FORM # HFWSPA GL 2006 or FORM # HFW GL 2006 unless the above 11 conditions have been met. Disclosure and Consent As part of my application for insurance I consent to the collection and use of personal information required for purposes of considering my application for errors and omissions insurance by the insurer and the authorized insurance broker, LMS PROLINK Ltd. AND/OR THE PROLINK INSURANCE GROUP. The insurer and the broker are authorized to collect, use, and disclose personal information and provide such personal information to third parties, as required for the purpose of underwriting this application for insurance, as permitted by the relevant provincial and federal privacy laws or other applicable laws. I understand that at any time I may ask to review the personal information pertaining to my application for insurance and the insurer and broker will be obligated to provide me with any information I am entitled to receive under the relevant provincial and federal privacy laws or other applicable laws. I have reviewed the information in this Application, gathered information from all partners/directors/ officers/ employees/agents under this entity whether present or prior regarding their knowledge or awareness any error, omission or negligent act in the performance of professional services for others. The Claim Information Forms, if any, that are attached to this Application include the details of : a. All fact situations and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against the us (the Applicant); b. All fact situations and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against us (the applicant) in the future. All such claims, suits and incidents have been reported to our (Applicants) current or prior insurer(s). It is understood and agreed that all such claims, suits, arbitrations, fact situations and incidents will be excluded from coverage under any policy issued by the Company. It is understood and agreed that failure to provide true and complete response to any of the questions, statements or request for information in this Application or to provide any other information material to this Application may, at the sole option of the Company, result in the voiding of the insurance policy issued in reliance on this Application and /or denial of coverage for specific claims asserted against us(the Applicant) or any other insured under the policy. The undersigned on behalf of Applicant and all other insured under any this policy issued by the Company, hereby waives any defence to an action by the Company for recession of such policy based upon misrepresentation of fact or failure to disclose material information in connection with this Application. Applicant agrees to hold the Company harmless from all loss as a result of any such misrepresentation or failure to disclose, including, without limitation, all costs and attorney fees incurred by the Company in connection with said action for rescission. JCTA August of 11

11 DECLARATIONS AND SIGNATURE The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. Although the signing of this Application does not bind the undersigned on behalf of the Organization or its Directors, Officers or Insured Persons to effect insurance, the undersigned, individually and on behalf of the Organization, its subsidiaries and their directors, officers or other Insured Persons agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be attached to and form part of the policy. The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. The undersigned warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement, on behalf of the Organization, its subsidiaries and their directors, officers or other Insured Persons. If the information in this Application materially changes prior to the Effective Date of this policy, the Organization will immediately notify the Company in writing and the Company may effect changes in the quotation. The undersigned further warrants that he/she (listed below) including all employees agree to and understand and will comply with all 11 policy warranties listed on page 9 of this application. It is further understood and agreed that failure to do so will relieve the insurer of all obligations to defend or investigate any reported claims. Name (Please Print) Date Signature Contact Us: Paul Attwood Account Manager 480 University Avenue, Suite 800 Toronto, Ontario M5G 1V2 Direct Tel: Toll Free: x JCTA@LMS.CA Fax: Toll Free Fax: JCTA August of 11