if applicable - Sports and Fitness Insurance Canada

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Trothen & McConkey Insurance
1054 Adelaide St. N., London, ON N5Y 2N1
Phone: 1-519-672-3224
Fax: 1-519-439-8865
Toll Free 1-888-346-6602
e-mail – [email protected]
TEETH WHITENING
APPLICATION
Brokerage Name (if applicable):
Broker Telephone:
Fax:
E-mail:
Legal Business Name:
Location Address:
City:
Province:
Postal:
City:
Province:
Postal:
Contact Person:
Bus. #
Fax #
E-mail:
Res. #
Cell #
Mailing (if different):
Expiry Date of Policy:
Previous/Current Insurance Company:
DESCRIPTION OF OPERATIONS
Any client under the age of 18?
Do parents stay on premise?
[ ] Yes [ ] No
[ ] Yes [ ] No
Do clients sign a waiver?
Are full records kept?
How long are records kept?
Do you bring any specialists into your premise to provide additional operations?
If so, Please describe:
Are there any operations or activities away from the premises?
If so, Please describe:
[ ] Yes [ ] No
[ ] Yes [ ] No
______ years
[ ] Yes [ ] No
[ ] Yes [ ] No
PROPERTY INFORMATION
Describe your location (Two story, strip plaza, shopping mall, etc.)
The Building Age:
No. of Stories:
Total Area of Building:
(Sq. Ft)
Do you own the building?
Total Area of your Facility:
CONSTRUCTION OF BUILDING
LATEST UPDATES
WALL:
Roof:
FULL
ROOF:
Concrete Block/Masonry
Steel Deck or Concrete
Heat:
Brick Veneer over Wood
Wood Joists
Plumbing:
Frame/Siding
Metal Clad
Electrical:
Yes
No
(Sq. Ft)
PARTIAL
YEAR
Sprinkler System
Yes
No
# of Smoke Detectors:
Yes
No
Burglar Alarm
Yes
No
# of Fire Extinguishers:
Yes
No
Fire Alarm
Yes
No
Alarm Monitored
Yes
No
Fire Hydrants within 500 feet
Yes
No
Average Hours of Operation:
to
Do you operate 24 hours:
Yes
No
Is there Any Bar/Restaurant Adjacent to your operation?
Yes
No
Is there a Variety Store adjacent to your operation?
Yes
No
Do you operate or rent space to other businesses?
Yes
No Annual rental income $
If yes, please describe:
Describe precautions taken to avoid slips and falls at entrances
Describe any steps:
Do you keep salt on hand for de-icing walkways / entrances?
Yes
No
Who does snow removal?
Are you in a basement location?
Teeth Whitening Application
1
July 2008
Please Complete This Section for ALL Employees & Sub-Contractors
# of Full time (F/T) Employees?
# of Part time (P/T) Employees?
________
________
# of CONTRACT People?
________
# of Employees over the age of 65? ________
List Names
LIABILITY
LIABILITY LIMIT REQUESTED:
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Gross Annual Receipts For Teeth Whitening: $
Product Used:
Active ingredient:

Carbamide Peroxide Concentration:
10%
more then 10%
If more than 10% please list:
%
If more than 10% please provide confirmation that Health Canada has received notice.
Hydrogen Peroxide

Concentration:
3%
more then 3%
If more than 3% please list:
%
If more than 3% please provide confirmation that Health Canada has received notice.
PROPERTY VALUES
Value of machine(s): $
Value of tenants improvements $
Value of Other Contents/Equipment: $
Value of stock: $
Make and Model(s) of Machine Used:
Has the company &/or staff had claims against them in last 5 years? [ ] Yes [ ] No, If yes please list:
Has prior coverage been on a Claims Made Basis?
Have you ever been cancelled for non-payment?
How many years in business?
Yes
Yes
No Retroactive date:
No
ADDITIONAL INSURED (i.e.: landlord, property manager, etc.)
LOSS PAYEE (i.e.: bank, leasing company, etc.)

If you provide any other services/procedures, you must complete next page.

Any person who knowingly and with intent to defraud any insurance company or another person, files and
application containing any false information, or conceals for the purpose of misleading information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime and subjects this person to criminal and
civil penalties.
Applicant Signature:
Title:
Date:
FAILURE TO ANSWER ALL QUESTIONS MAY RESULT IN A DELAY PROCESSING YOUR SUBMISSION
Teeth Whitening Application
2
July 2008
This page is to be completed if services/procedures other than teeth whitening are performed
under this business/name.
SURVEY OF OPERATIONS
Type 1
Hair Cutting / Colouring
Makeup - Non-Permanent
Gel Nails
Body Wraps
Ear Piercing
Supplement Sales
Facials
Manicure / Pedicure
Spray Tanning Handheld
Annual Receipts for Type 1 (must have estimate in order to quote):
Waxing / Sugaring
Nails – Acrylic
$
Type 2
Body Piercing
Henna Tattooing
Oxygen Bar
Aromatherapy
Reiki
Electrolysis
Acid/Glycolic Peels
Semi-Permanent Makeup
Spray-on Tattooing
Dry Heat Sauna Beds
Massage Registered
Reflexology
Microdermabrasion
Ear Candling
Toning Beds
#
Vibration Plate Machines #
Massage Non-Registered
Aqua Massage Beds
#
Tanning (Beds/Booths) #
Annual Receipts for Type 2 (must have estimate in order to quote):
$
Type 3
Laser Treatments
Sclerotherapy
IPL Treatments
Permanent Makeup / Micro-pigmentation
Annual Receipts for Type 3 (must have estimate in order to quote):
Other Operations
Injections/Fillers (e.g. Botox)
Stripping for Spider Veins
Chiropractors/Physical Therapists
Permanent Body Tattooing
Other -
$
Annual Receipts
$
$
$
$
$
$
$
If you have not checked any of the items with corresponding pages, please sign below and remit to our
office.
I understand and agree that any policy issued will be based upon the information contained in the application and any related forms. I
understand that any forms or other material submitted with the application constitute part of my application for insurance. I
further understand and agree that any misrepresentation or failure to provide true and accurate information may result in the voiding of
and/or denial of claims under any policy issued at the option of the company.
By submitting this application and any related forms to Sports & Fitness Insurance Canada, you provide Trothen & McConkey
Insurance Broker Ltd. with your consent to the collection, use and disclosure of your personal information, including that previously
collected, for the purpose of: communicating with you; assessing your application for insurance and underwriting your policies;
evaluating claims; detecting and preventing fraud; analyzing business results; and acting as required or authorized by law.
Applicant Signature:
Teeth Whitening Application
Title:
3
Date:
July 2008
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