Contact Information
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required:
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Applicants Name:
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Mailing Address:
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County:
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City:
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State:
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Zip:
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Phone:
Fax:
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Email:
Cell:
Business Information
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Company:
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Address:
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County:
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City:
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State:
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Zip:
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Phone:
Fax:
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Email:
Cell:
Website:
Yes
No
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Current Client with Mourer Foster
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Previous Mourer Foster Client with lapse policy
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?
Number of losses in past 3 years:
Percentage of work done at this shop (Tattoo):
Percentage of work done at this shop (Piercing):
Prior Insurance Company:
How would you like to make payment:
1 Annual
11 Direct Bill
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:
Yes
No
Piercing Procedures
Do you ever pierce minors? (parental consent required)
Yes
No
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
Do you want nose, ear, and navel piercing for minors?
Yes
No
Do you perform piercing on genitals?
Yes
No
Do you have a private piercing room?
Yes
No
How are hard surfaces disinfected?
Have all piercers had formal instruction in body piercing?
Yes
No
How do you sterilize jewelry prior to insertion?
Please list all types of piercings below that your piercers perform other than the following (Ears, Nose, Navel, Eyebrows, Nipple, Lip, Tongue & Genitals):
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:
Artists and Piercers Information
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
Name:
Owner
Independent Contractor
Employee
Years of piercing experience:
Years of tattoo experience:
Does this technician do Permanent Makeup?
Yes
No
Does this technician need Piercing Coverage?
Yes
No
Do you Pierce minors?
Yes
No
Do you do Surface and Dermal Anchor Piercings?
Yes
No
Years of Surface and Dermal Piercings experience:
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
If Claims Made form, what is most recent Retroactive Date?:
Have you had any claims arising from any body piecing, tattooing or any other professional activities?
Yes
No
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
No
If yes, please provide details:
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615 North Capitol Avenue - Lansing MI 48933
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