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

Contact Information
* required:

* Applicants Name:

* Mailing Address:

* County:

* City:

* State: * Zip:

* Phone:

Fax:

* Email:

Cell:

Business Information

* Company:

* Address:

* County:

* City:

* State: * Zip:

* Phone:

Fax:

* Email:

Cell:

Website:

Yes	No
		* Current Client with Mourer Foster
		* 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

Piercing Procedures

Do you ever pierce minors? (parental consent required)

Yes

List all equipment used to pierce:

How is the body prepared before piercing:

Do you use a piercing gun?

Yes

If yes, under what circumstances?

Do you use sterile needles with each individual piercing?

Yes

Do you want nose, ear, and navel piercing for minors?

Yes

Do you perform piercing on genitals?

Yes

Do you have a private piercing room?

Yes

How are hard surfaces disinfected?

Have all piercers had formal instruction in body piercing?

Yes

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:

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

If yes, please provide details: