First Name:

Last Name:

Business Name:

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip Code:

Phone Number:

Fax Number:

E-Mail Address:

PROPERTY ADDRESS (if different)


Property Address:


Property City:

Property State:


Property Zip Code:



Please Describe the Exact Nature of Your Business


Type of Ownership:


Number of Owners:

Number of Full Time Operators:

Number of Part Time Operators:

Number of Stations:

Annual Payroll of Owners:

Annual Payroll of Employees:

Total Annual Gross Receipts:

Salon Location:


Total Square Footage of the Building Your Business Is In:

Square Footage Of Your Business Only:

Business License Number:

License Type:

Years of Experience:

How Many Years Have You Operated This Business:

How Many Stories Is The Building:

Construction Type:


Roof Type:


Roof Updated:

yes no 

If Yes, Estimated Year Roof was Updated:

Protection Distance:

Is The Business In A Brush Area?

yes no 

Is This Business Open 24 Hours A Day?

yes no 

Is There Storage More Than 1500 Sq Ft?

yes no 

Are There Smoke Detectors At This Location?

yes no 

Smoke Alarm:


Fire Extinguisher:


Deadbolts On All Doors?


Circuit Breakers:

yes no

Electrical Updated:

Heating - Air Conditioning, Thermostatically Controlled?:


Heating - Air Conditioning, Central?


Plumbing Updated:


If Yes, Estimated Year Plumbing was Updated:

Interior Automatic Fire Sprinklers: 

Theft Alarm:

Fire Alarm:



Any Deep Frying (Food)?


yes no 

Do Electrolysis Services?

yes no 

Do Hair Removal by Electronic Tweezer Services?

yes no 

Do Chiropody or Podiatry Services?

yes no 

Do Wart or Mole Removal Services?

yes no 

Do Reducing, Slendering or Exercising Services?

yes no 

Do Tanning Services?

yes no 

Do Skin Treatments or Facial Services?

yes no 

Do Electric or Steam Baths or Sauna Services?

yes no 

Do Hair Implants or Transplant Services?

yes no 

Do Hair Weaving Services?

yes no 

Do Ear Piercing Services?

yes no 

Do Bodywaxing Services?

yes no 

Do Bodywrapping Services?

yes no 

Do Nail Sculpturing Services?

yes no 

Do Tattoo Services?

yes no 

Do Permanent Make-up Services?

yes no 

Do Hair Straightening Services?

yes no 

If Yes, Chemical Base of the Relaxer:


Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products?

yes no 



Building Coverage:


Other Structures Coverage:

Business Contents Coverage:

Loss of Use Coverage:

Liability Limits Requested:

Policy Deductible:



Losses-Claims in the last 5 years: 



If yes, date, amount paid and description of each loss-claim

Current Insurance Company:

Expiration Date:

Current Premium $:

Questions or Comments
to help the Agent:

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Thank you for your interest.