Spa & Wellness Program – Renewal Application
Page 1 of 2
Brokerage:
Producer Name:
Insured Name:
Policy No.:
Have there been any changes in property limits from last year? If yes, please provide the renewal limits required for each
category below.
Building (if require):
$
Equipment:
$
Leasehold Improvements:
$
Stock:
$
Laser Machine:
$
Total Anticipated Annual Gross Receipts
$
.00
# of Full Time (F/T) Employees?
# of Part Time (P/T) Employees?
# of Contract People?
Operations of Insured:
Basic Esthetics:
Y or
N
Anticipated Gross Receipts: $
Please identify which operations apply below:
Acid Peels less than 31% solution concentration
Y or
N
Hypnotherapy other than for past life regression and
entertainment
Y or
N
Acupuncture other than Moxibustion acupuncture
Y or
N
Infrared Saunas and massage booths / beds
Y or
N
Acupressure
Y or
N
Ionization detoxification
Y or
N
Aquatic massage beds
Y or
N
Iridology
Y or
N
Biofeedback therapy
Y or
N
Make Up – non permanent
Y or
N
Body Wraps
Y or
N
Manicure/pedicures
Y or
N
Brain wave harmony
Y or
N
Massage including relaxation massage, registered
massage, reiki, reflexology, and aromatherapy, but
does not include services to children under the age of
12 and Myofacial massage
Y or
N
Cellulite treatment other than cellulite reduction weight loss
Y or
N
Neuro emotional Clearing
Y or
N
Colon irrigation
Y or
N
NLP – Neurolingulistic Programming
Y or
N
Ear candling
Y or
N
Nutritional consulting to follow the Canada Food Guide
only
Y or
N
Energy healing
Y or
N
Oxygen treatments other than hyperbaric chambers
Y or
N
Electrolysis
Y or
N
Piercing – ears and nose only
Y or
N
EFT – Emotional Freedom Technique / Clearing
Y or
N
Shamanic healing
Y or
N
Eyebrow Tinting
Y or
N
Spray tanning
Y or
N
Facials
Y or
N
Spray tattooing
Y or
N
Glitter Tattooing – non permanent
Y or
N
Sugaring
Y or
N
Hair cutting and related service other than hair extension,
wig/hair piece fitting / sales
Y or
N
Threading
Y or
N
Henna Tattooing
Y or
N
Toning beds
Y or
N
Hydration machine
Y or
N
Wart removal by solution only
Y or
N
Hydrotherapy salt floatation chambers
Y or
N
Waxing
Y or
N
Mid Range Esthetics:
Y or
N
Anticipated Gross Receipts: $
Please identify which operations apply below:
Acid peels greater than 30% but less than 61% solution
concentration
Y or
N
Micropigmentation
Y or
N
Arasy machines
Y or
N
Mole removal by solution only
Y or
N
Body vibration fitness machines
Y or
N
Myofacial massage
Y or
N
Electrocoagulaton
Y or
N
Radio frequency treatments
Y or
N
EMS – Elector Muscular Stimulation including Acuscope and
Y or
N
Sclerotherapy
Y or
N
Rev. Jan 30, 2015
Spa & Wellness Program – Renewal Application
Page 2 of 2
Myopulse
Endermologie
Y or
N
Skin and micro needling
Y or
N
Fluid Isometrics
Y or
N
Skin tag removal by solution or laser
Y or
N
Laser / IPL / EPL / LHE various operations but not including
laser treatments for purposes other than skin and hair
treatment
Y or
N
Teeth whitening
Y or
N
LILT & LLLT – low intensity laser therapy for weight
reduction and gain, addictions, mental illness and pain
reduction
Y or
N
Thermolysis
Y or
N
Micro current treatment
Y or
N
Thermo-Lo
Y or
N
Microdermabrasion
Y or
N
Vibrodermabrasion
Y or
N
Cellulite reduction and body contouring and slimming by electronic device
Y or
N
Bio resonance diagnostics
Y or
N
Tattoo removal by Laser / IPL / EPL / LHE
Y or
N
Body injections for cosmetic purposes, including but not limited to Botox. Juvederm, Restylane, and Teosyal treatment
Y or
N
High End Esthetics:
Y or
N
Anticipated Gross Receipts: $
Please identify which operations apply below:
Miscellaneous Professional Services:
Y or
N
Anticipated Gross Receipts: $
Please identify which operations apply below:
Eyelash dipping
Y or
N
Tooth gems
Y or
N
Eyelash extensions
Y or
N
Wigs and Extensions – Not attached by
adhesive
Y or
N
Eyelash tinting
Y or
N
Latisse
Y or
N
Hair extensions
Y or
N
Holistic Vitamins
Y or
N
Tanning – UV
Y or
N
Y or
N
Teaching Operations:
Y or
N
Anticipated Gross Receipts: $
Teaching and students offering service(s) to the public while under supervision
PLEASE NOTE:
The applicant agrees to notify the company of any material changes that have occurred since the inception of this policy and further understands that claims may
be denied if information regarding these material changes were not provided.
The purpose of this questionnaire is to assist in the underwriting process. Information contained herein is specifically relied on in determination of insurability. The
under-signed, therefore, warrants that the information contained herein is true and accurate to the best of his/her knowledge, information, and belief. This
questionnaire and the application shall be the basis of any insurance policy that be issued and will be part of such policy.
A consumer report containing personal, credit, factual or investigative information about the applicant may be sought in connection with this application for
insurance or any renewal, extension or variation thereof. Signing of this form does not bind the Applicant to purchase the insurance or the Insurer to accept the
risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.
Signature of Applicant:
Date:
Signature of Broker:
Date:
Broker Firm:
Broker AGT #:
Broker Email:
Tel:
Fax:
NOTE: THERE IS NO AUTOMATIC RENEWAL. WE REQUIRE THIS FORM COMPLETED AND RETURNED PRIOR TO THE
EXPIRY DATE IN ORDER FOR US TO OFFER RENEWAL TERMS.
Premier Canada Assurance Managers Ltd. is one of Canada’s largest Managing Underwriting Agents. The underwriting insurance carrier varies by line
of business and region - please refer to specific quote for declaration of the underwriting insurance company(s).
** Email application and attachments to - processingcommercial@premiergroup.ca **
Vancouver - T 604.669.5211
F 604.669.2667
London - T 519.850.1610
F 519.850.1614
Rev. Jan 30, 2015