BARBER SHOP WORKSHEET

First Name: Last Name: Business Name: Mailing Address: Mailing City:   Mailing State: Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Mailing Zip Code: Phone Number: Fax Number: E-Mail Address: PROPERTY ADDRESS (if different)   Property Address:   Property City: Property State: California Property Zip Code: UNDERWRITING INFORMATION   Please Describe the Exact Nature of Your Business   Type of Ownership: Individual Partnership Joint Venture Corporation   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: Store Hotel Your Home Dept Store Office Building   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: 1 2  Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated: yes no  If Yes, Estimated Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  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: yesno Fire Extinguisher: yesno  Deadbolts On All Doors? yesno Circuit Breakers: yes no Electrical Updated: Yes, Updated No  Heating - Air Conditioning, Thermostatically Controlled?: yesno  Heating - Air Conditioning, Central? yesno  Plumbing Updated: yesno If Yes, Estimated Year Plumbing was Updated: Interior Automatic Fire Sprinklers:  None Partial Full  Theft Alarm: None Local Central  Fire Alarm: None Local  ADDITIONAL SALON SERVICES   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:  Sodium Hydroxide Ammonium Thioglycolate   Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? yes no  COVERAGE INFORMATION   Building Coverage:   Other Structures Coverage: Business Contents Coverage: Loss of Use Coverage: Liability Limits Requested: $100,000 $300,000  $500,000 $1,000,000  Policy Deductible: 100 250 500 750 1000 2500 5000  MISC INFORMATION   Losses-Claims in the last 5 years:    none one two three four five   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: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.