The Beauty Products Insurance Program Application

Stratus Insurance Services, Inc.
260 South 2500 West, Suite 303
Pleasant Grove, UT 84062
1-866-395-1308
1-801-763-1374 FAX
beauty@stratusins.com
online application: www.stratusins.info/renewal.php

Beauty Products Insurance Program
RENEWAL APPLICATION

Instructions:

Answer all questions. If the answer is NONE, please state "NONE." Attach copies of all labels including the ingredients with the application. Application must be signed and dated by an officer of the company

A. Applicant

1.	Company/Insured Name:
2.	Owner/Contact Name:		E-mail Address:
3.	Mailing Address:
4.	Physical Address Address ( Same as Mailing):
5.	Phone #:	Fax #:		Website:

If you are an insurance agent filling out this application for your client, please fill in your contact information.
8.	Agent Name:		Agent E-mail Address:
9.	Agent Phone #:

In the past 12 months, did you have any changes of the following:

Name or Location of the Company	Yes No
Please explain (i. e. old name, new name, date of change):
Ownership/Operation Changes	Yes No
Please explain (i. e. added partners, changed entity type, date of change):
Added/Discontinued Products?	Yes No
Please explain:

B. Product and Sales Data

1. Please list products you manufacture and distribute. Please provide breakdown of sales for each product

Descriptions of Major Products (i.e. lotions, soaps etc)	PRINCIPAL END Usage (i.e. night face cream)	Manufacture or Distribute (if you are importing your product, put manufacture)	% OF GROSS ANNUAL SALES (i.e. creams 20%, soaps 80%)

2. Sales Exposure Information

Year	Domestic Sales	Foreign Sales	Total Sales
Next 12 months (Projected)
Last 12 months (Expiring)

C. Loss History

Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last five (5) years? Yes No

D. Manufacturing / Distribution / Labeling

Are all the products sold considered "Generally Regarded Safe" by the FDA?

Yes No
My product does not require FDA Approval
Are your warning labels comply with FDA statutory warning labeling requirements?
Yes No
In the past 12 months have you changed labels, name or ingredients of the products? If yes, attach labels
Yes No

E. Marketing

Percentage of total sales to:

Wholesalers:

Retailers:

Consumers:

2.	Do you have a retail location?	Yes No
What other* products are sold at your store?*
3.	Do you have separate coverage for those products?	Yes No

F. Loss Prevention

In the past 12 months have you implemented/imrpoved any of the following:

	Written Claims/Complaints Procedure	Yes No
	Written Product Recall/Withdrawal Plan	Yes No
	Written Product Safety Program	Yes No

G. Coverages

Please confirm you understand that Vitamins, Supplements, Ingestible Products, Invasive Body Inks, Products that Require Prescription and Children Toys are excluded from the policy and there will be no coverage for claims arising out of those products
Yes, I understand and agree
Please confirm you understand that there is no professional liability coverage for estheticians, massage therapists, aromatherapists, hairdressers and salon operators.
Yes, I understand and agree
Are you interested in quoting Workers Compensation Coverage? Yes No
Are you interested in quoting Business Income and Property Coverage? Yes No
If you are interested in other Coverages, please list:

COMMENTS:

Attachments

Please upload brochures/product labels, loss runs, pictures or list of ingredients: Upload
Uploaded files:

Warranty

NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.

CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied).

IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.
Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, partners, directors, officers and employees.
Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective date).

Signature/Name of applicant:

Date:

Title:

(owner, partner, officer)

Beauty Products Insurance Program RENEWAL APPLICATION