TribalInkSurance - Liability insurance coverage for Tattoo and Piercing Artists, Parlors, and Professionals

Contact Information
* required:

* Contact Person:

* Address:

* County:

* City:

* State: * Zip:

* Phone:

Fax:

* Email:

Cel:

* Current Insurance Co.:

* Current Premium Payment:

Mo.

Qtr.

Half

Year

* Date of Birth:

Yes	No
		* Current Client with Mourer Foster
		* Previous Mourer Foster Client with lapse policy

Please check this box if property coverage is required.
If you DO NOT require property coverage, please proceed to the "Select the coverage level you're interested in" section below where you can choose between the
"Barbed Wire" and "Tramp Stamp" packages which can be purchased online.

If you DO require property coverage, please fill out the following information and you will be able to select the "Dragon" package at the end of the form. A custom quote will then be reviewed and approved by our underwriters and forwareded to you.

Building currently insured for:

If new, list purchase price:

Liability Limit:

100,000/300,000	300,000/500,000	500,000/800,000
800,000/1,000,000	1,000,000/2,000,000

Year building was built:

Size (square footage):

Number of Stories:

Occupied Area:

25%

50%

75%

100%

Exterior Material:

Type of structure:

Pole Building

Masonry (Block)

Frame (Wood)

Type of Basement:

Slab on Grade

Crawl Space

Full Basement

Type of Heat:

Electrical

Gas

Propane

Equipment & Furnishings

$5000	$10,000	$15,000
$20,000	$25,000	$30,000
$35,000	$40,000	$45,000
$50,000

Special items in building:

Select the coverage level you're interested in:


	Barbed Wire		Tramp Stamp		The Dragon (only available with property coverage)

Business Information

Entity Type:

Individual	Partnership
Limited Liability Corp.	Corporation
Independent Contractor	Other

Number of years in business:
Number of years experience in the Piercing trade:
Number of years experience in the Tattoo trade:
Are you a member of any trade organizations?	Yes	No
If yes, which one?
Do you operate any retail stores that do not have tattoo or piercing operations?	Yes	No

Underwriting Information

Is a release / waiver form signed by everyone?		Yes		No
Do you provide an aftercare form for each client?		Yes		No

How do you sterilize equipment and material prior to use:

Do you use an autoclave?	Yes	No
If no, please provide your method of sterilization:
Is spore testing done?	Yes	No
If yes, how often?
Who conducts the testing?
Type and Manufacturer of your sterilization equipment?

Do you have hot & cold running water on site?	Yes	No
Do you wear new gloves with each procedure?	Yes	No
Are you in compliance with all city, county and state ordinamces?	Yes	No
Do you work out of your home?	Yes	No
In the next 12 months, how many convention / trade shows will you attend as a vendor / demonstrator?
How many total days per year?
Have you had an apprenticeship in tattooing?	Yes	No
Have you had formal instruction in Body Piercing?	Yes	No
Have you had formal training in the application of permanent cosmetics / makeup?	Yes	No

Please provide a description of your training and experience:

Policy Limits

Requested Effective Date:
Requested Liability Limits:	$500,000 $1,000,000
Do you want to include Professional Liabilty Coverage for your artists, piercers and apprentices?	Yes	No

Include "Defense Costs" within the liability policy limits:
Make "Defense Costs" in addition to liability policy limits:

Piercing Procedures

Do you ever pierce minors?	Yes	No
What percentage of your gross sales are from piercing minors?
Is written parental consent required?	Yes	No
Do you require parent to be present during piercing of minors?	Yes	No

If no, please explain why:

List all equipment used to pierce:

How is the body prepared before piercing:

Do you use a piercing gun?	Yes	No
If yes, under what circumstances?
Do you use sterile needles with each individual piercing?	Yes	No
Are your piercing procedures limited to eyebrow, nose, lip, ear, nipple and navel?	Yes	No
How are hard surfaces disinfected?
The jewelry you use / sell is made of what materials?
Is all jewelry used manufactured in the U.S. or from Cold Steel / Wild Cat in the UK?	Yes	No
How do you sterilize jewelry prior to insertion?
How many body piercings have you performed in the last 12 months, excluding micro-dermal anchors?
Do you do micro-dermal / surface anchor procedures?	Yes	No
If yes, how do you create the opening?
How many micro-dermal / surface anchors have you performed in the last 12 months?
Do you remove the anchors?	Yes	No
If yes, how are they removed?

Tattooing Procedures

Are all pigments used from US manufacturers?	Yes	No
In no, explain:
Do you dispose of pigments after each client?	Yes	No
Do you ever re-use needles?	Yes	No
Do you apply temporary or sticker tattoos?	Yes	No
If yes, are the temporary tattoos made in the US?	Yes	No
Do you apply permanent makeup?	Yes	No
If yes, what type:

Schedule of Locations, Artists and Piercers

Covered Locations:

Address	City	State	Zip

Name	License#	Artist	Piercer	Apprentice	Yrs. Exp.	Title

Do any of the listed individuals above own any other business or sell products in their name?

Yes

If yes, please list those individuals and the business and / or products:

Additional Insureds

Name	Address, City, State, Zip	Relationship (Landlord, Etc...)

Insurance and Claim History

Do you currently have general liability insurance?		Yes		No
Do you carry professional liability insurance?		Yes		No

If yes, please provide the following information:

Insurance Co.	Policy #	Exp. Date	Liability Limit	Annual Premium

In the last 5 years, have you had any claims arising from any body piecing, tattooing or any other professional activities?

Yes

If yes, please provide claim details:

Date of Claim	Desc. of Incident	Nature of Injury	Equip. Involved	Amt. of Settlement

Do you have any knowledge of an event, circumstance or occurence (not listed above) that has occurred prior to the effective date of this policy, or do you foresee that a claim may be brought as a result of said event, circumstance or occurence?

Yes

If yes, please provide details: