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Introduction

0% Complete

Please complete the following application for Total Body Pac.  Upon completion, your application will be sent directly to our underwriters for review and rating.  We will forward a quote within 1 business day.

You can save your application and come back to it at any time by clicking the save and resume button located at the top right corner of the page.  There are up to 9 sections that must be completed (depending on your application), each should take 1-2 minutes.

When you are finished, you will have an opportunity to review your entire application and make changes if you wish.

If you have any questions, please call our underwriters directly at 516-417-5117.


Note: To apply for Property or General Liability coverage, you must apply for Professional Liability

General Information 1 of 9

11% Complete

Applicant Information
Name of Corporation or LLC (include “Inc”, “Corp”, “LLC”, etc.):
Name of business (your “dba” or “t/a” name):
Name of business owners:
Website:
FEIN (Or Social Security Number of Owner):
Business Information


Current year (estimated) Previous Year
Total Annual Gross Receipts/Revenues:
$
$
How many years have you owned this business?
Third Parties

If yes, please list and describe each one below:

Add another interest

Insurance Information 2 of 9

22% Complete

TOTAL BODY PAC
New Hampshire Insurance Company, Administrative Office: 200 State Street, Boston MA 02109
Professional Liability Insurance Application, Occurrence

Name of Corporation or LLC (include “Inc”, “Corp”, “LLC”, etc.):
Name of business (your “dba” or “t/a” name):
Name of business owners:
Website:
FEIN (Or Social Security Number of Owner):
Name Phone Email Title
Contact
Add another

NOTE: If there are multiple locations and you selected Property coverage, you will need to complete the Property Application for each location.

List any professional associations in which the Applicant is a member:
Add another association



**this limit available for tattoo & body piercing only

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 deductible of $250 shall apply to tattoo policies.


If yes, list all locations and square footage of each office:

Add another location
Carrier Policy Number
4. Previous Insurance Carrier & Policy Number (Not required in Missouri):
5. Previous liability coverage written on:
6. Has any previous carrier cancelled or not renewed a policy? (Not required in Missouri)

7. Should your landlord be named as an additional insured?

Professional Services Information 3 of 9

33% Complete

1. Please check the professional services that you perform and for which you desire coverage under the policy.

NOTE: Any professional service for which you do not provide such information will not be covered under the policy.
NOTE: Checking any professional service does not obligate us to insure it.









2. Please indicate the numbers of employees, independent contractors, and students performing the professional services shown above and for whom you desire coverage under the policy.

Employee Independent Student
Tattoo
Micropigmentation
Micropigmentation Training
Body Piercing
Hair / Nails / Cosmetics
Aestheticians
Massage Therapists
Electrologists
TOTAL number providing services
(# of units):
Tanning Beds / Booths / Units
Hydrotherapy Tubs / Hydrotherapy Tables / Showers
Exercise Equipment
3. Are all technicians licensed if required by law?
4. Are any employees or independent contractors medical doctors?


5. If you have checked “Body Piercing,” “Micropigmentation,” or “Tattoo,” please answer the following:

a. Do you always obtain a medical history for every client?
b. Do you always supply a patient / customer with aftercare information?

NOTE: Distribution of aftercare information is required by policy

c. Do you always obtain a signed consent or release form?

NOTE: Use of consent / release form is required by policy

d. Do you use piercing guns?



NOTE: Micropigmentation technicians must attach a copy of training certificate or diploma.


6. List schools you attended or graduated from and describe any training received:

Add another school

Loss Information and Warranty 4 of 9

44% Complete

1. Have there been any claims reported in the last five years?
2. Are there any pending claims against the applicant?
3. 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(s) under the proposed policy?

If yes, attach a complete description including name of claimant, date of claim, nature of injury, and amounts paid.

Supplemental Information 5 of 9

55% Complete

1. Do you offer massage services to minors (under 18 years old)?
2. Do you obtain criminal background checks on all massage therapists?
3. Do you offer chemical/acid peel services?
4. Do you offer sclerotherapy, telangiectasia, or any services to minimize the appearance of veins?
5. Do you offer any services intended to remove skin tags, warts, moles, or other growths?
Chemical Peel Supplemental Questions
a. Do you use Trichloroacetic acid (TCA) preparations with concentrations over 20%?
b. Do you use AHA preparations with concentrations over 30% with pH lower than 3.0?
c. Do you use Jessner’s solution preparations with concentration over 14%?
d. Do you use any medical-grade peels?


Fraud Warnings 6 of 9

66% Complete

NOTICE TO APPLICANTS: 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 ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.

NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE 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.

NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO MINNESOTA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DECEIVE AND DEFRAUD, MAKES ANY MATERIAL ORAL OR WRITTEN MISREPRESENTATION OR WHO HELPS ANOTHER MAKE A FRAUDULENT MISREPRESENTATION TO AN INSURER, COMMITS A FRAUD AGAINST THE INSURER AND IS GUILTY OF A CRIME.

NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO NEW YORK APPLICANTS: 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1).

NOTICE TO PENNSYLVANIA APPLICANTS: 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.

NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT,
FINES AND DENIAL OF INSURANCE BENEFITS.

Fraud Statement

I understand that entering incorrect information in this application could void the insurance coverage.  My electronic acceptance below represents that all questions presented have been answered truthfully and correctly.  Submitting this form or rendering premium does not bind the applicant or company/underwriter to complete the insurance contract, but it is agreed that this form shall be the basis of the contract and shall form part of the policy, should a policy be issued.

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Any person who knowingly and with intent to defraud an insurance company files an application for insurance containing false information, or conceals information concerning any fact material hereto for the purpose of misleading, commits a fraudulent insurance act.

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Electronic Signature

I agree that my name as typed in the field below is equivalent to my signature on this document and I consent to conduct the transactions to which this document is applicable by electronic means, including the delivery of any documents to me.

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General Liability Information 7 of 9

77% Complete

1. Do you perform any of the following?
a. Repair or install equipment or machines?
b. Rent equipment to others?
c. Sell products under your own label?
d. Sell products which you repackage, re-label, or re-manufacture?
e. Do you manufacture or re-bottle any products at your business location?
2. Please indicate whether any of the following optional coverages ($1,000,000) are desired:
a. Employee Benefits Liability
b. Hired and Non-Owned Auto Liability
c. Stop Gap Liability (ND, OH, WA, WV, and WY only)

Property Information 8 of 9

88% Complete

Please answer these questions based on your primary location and building. If you have additional locations or buildings, you must complete this section for each by clicking "add another location" at the bottom. Home based businesses should complete the following questions based on the business portion of the home.

Property Information
Location Address
1. What is the desired Property Deductible?
2. Is the business within 1,000 feet of a fire hydrant?
3. Is the business within 5 miles of a Fire Station?
4. What is the 100% replacement value of the business personal property?
$
5. What is the construction of the building where the business is located?

6. What is the square footage of the space occupied by the business?
7. How many stories in the building?
8. What is the original year the building was built?
9. What is the square footage of the entire building?

10. If the building is over 10 years old, indicate the year each of the following was updated:

11. Please indicate the other types occupants in the same building (check all that apply):

Describe
Left:
Right:
Behind:
Above:
Below:

12. Please indicate the types of occupants in neighboring buildings (check all that apply):

Describe
Left:
Right:
Behind:
13. Does the building have an automatic sprinkler system covering 100% of the premises?

Answering yes will give (in most cases) a substantial discount on property insurance.


14. Do you own the building itself and/or do you need to insure the building itself?
$

15. If you answered yes to question 14 above:

a. Is it a business condominium?
b. Are you renting/leasing the property under a triple net lease?
c. Are you renting a portion of the building to others?
$
Add another location

Premium and Loss History Information 9 of 9

99% Complete

Applicant Information
1. Name of Corporation or LLC (include “Inc”, “Corp”, “LLC”, etc.):
Name of business (your “dba” or “t/a” name):
Name of business owners:
2. Number of Years in business
3. Have you carried any business insurance in the past three years?

If yes, provide the following information for all such policies:

$
Add another coverage period

IF YOU ANSWERED YES TO QUESTION 3 ABOVE, PLEASE RETURN THIS PAGE WITH 3 YEARS LOSS RUNS FROM YOUR PRIOR INSURANCE CARRIER.

4. Have there been any claims in the past three years (whether or not insured)?

If yes, provide the following information for all such claims:

$
Add another claim

We have not carried business insurance coverage during the past three years. There have been no claims (insured or otherwise) during the past three years. We are not aware of any circumstances during the past three years which may give rise to a claim.



IF YOU ANSWERED NO TO QUESTIONS 3 AND 4 ABOVE, PLEASE SIGN BELOW AND RETURN.

NOTICE TO APPLICANTS: 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 ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

Electronic Signature

I agree that my name as typed in the field below is equivalent to my signature on this document and I consent to conduct the transactions to which this document is applicable by electronic means, including the delivery of any documents to me.

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Need assistance with this form?

If you need any assistance with the Total Body Pac online application form, please contact us at 516-417-5117 or info@totalbodypacinsurance.com.

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