InsureLine Brokers (Complete)

Broker Name
First Last
Producer Name
First Last
Phone
Fax
Email
General Information
Legal Business Name
Location Address
Street Address Address Line 2 City Province Postal Code
Is this the mailing address?
- Yes
- No
Mailing Address
Street Address Address Line 2 City Province Postal Code
Contact Person
First Last
Email
Website Address
Phone
Fax
Residential
Cell
Expiry Date of Policy
MM slash DD slash YYYY
Current Insurance Company
Risk Ever Been Cancelled
- Yes
- No
Target Premium
Number of Years in Business
Number of Years Experience
Please provide a Brochure of your Operations
Max. file size: 32 MB.
Has the company had claims against them in last 5 years?
- Yes
- No
Please explain
Has the any staff (including contract staff) had claims against them in last 5 years?
- Yes
- No
Please explain

Teaching Operations
Estimated Gross Annual Receipts
Teaching and students offering service(s) to the public while under supervision
- Yes
- No
Other Operations
Do you undertake other operations?
- Yes
- No
Estimated Gross Annual Receipts
Please describe

Please Complete This Section for ALL Full Time & Contract Employees.
# of Full time (F/T) Employees?
# of Part time (P/T) Employees?
# of Contract People?
List
Name Years of Education Year of Experience Operations of each individual F/T, P/T or Contract Certification Attached?
Additional Insured
(i.e. Landlord)

Cyber Liability
Does the Company store any medical/health information for clients?
- Yes
- No
Does the Company follow the minimum standards under the HIPAA (encryption and firewalls in place)?
- Yes
- No
Does the Company follow the minimum standards under PIPEDA or the respective PIPA requirements (encryption and firewalls in place)?
- Yes
- No
Higher cyber limits may be available, please contact your underwriter for details.
- Yes
- No
The applicant agrees to notify the company of any material changes in the answers to the questions on this questionnaire which may arise during the course of this policy issued and further understands that claims may be denied if information regarding these material changes was 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. For purposes of the Insurance Companies Act (Canada), any document would be issued in the course of Lloyd’s Underwriters’ insurance business in Canada.
Insured Signature
Date
MM slash DD slash YYYY

Health & Wellness Program – Basic Spa Operations Application

Step 1 of 10

General Information

Property Information

'Property Values' (If you had to replace the following items today)

Liability Information

Description of Operations:

CONSENT TO OBTAIN CREDIT INFORMATION

Basic Esthetics

Mid-Range Esthetics

High End Esthetics:

Miscellaneous Professional Services

Teaching Operations

Other Operations

Wet Areas

Description of Operations

Are any of the following operations conducted:

Please Complete This Section for ALL Full Time & Contract Employees.

Cyber Liability

Name	Years of Education	Year of Experience	Operations of each individual	F/T, P/T or Contract	Certification Attached?