Fillable - C-APP041-0815 Tanning Bed - Suppl App

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- C-APP041-0815 Tanning Bed - Suppl App

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C‐APP0041‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - TANNING BED - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Body wraps with the exceptional of herbal wraps
Body Piercing
Tattoos
UVB bulbs that exceed 8.5%
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
OPERATIONS / EXPOSURES
Tanning Beds
Number of tanning beds: _______
Spray tanning in booth(s)
Spray tanning performed manually by employee(s)
Number of Spray Tanning Booths (if any): _____
Spray tanning performed off premises
Manufacture or sale of products designed, manufactured to the insureds specifications, or with the insured’s label
(describe):
Other operations (describe): _________________________________________________________________
C‐APP0041‐0815 Page2of3
TANNING BED - SUPPLEMENTAL APPLICATION
CONTROLS
Attendant is on duty at all times
Goggles supplied to each customer
Signs posted advising tanning is prohibited if on medications or pregnant
Timers are controlled by attendant
Units disinfected after each use by employees
Waivers (signed) are permanently maintained on file, as well as time and usage sheets
Waivers signed by each customer or parent/guardian if customer is under legal age
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable.
Risk Transfer – Subcontractors: (check if applicable)
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of insurance - Always obtained from a subcontractor prior to any work being done for you.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
MEMBERS
Number of annual memberships: __________
RECEIPTS
Tanning related receipts only
$
All other receipts
$
Total Receipts – All Operations
$
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement:
Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
C‐APP0041‐0815 Page3of3
TANNING BED - SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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Completed 18 July 2020

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