BEAUTY PARLOR OR BARBER SHOP SUPPLEMENT

Complete this supplement and submit with ACORD Application(Additional comments may be included on the reverse side.)

Applicant

1. Type of Operation: Barber Shop Beauty Salon Manicure Shop

2. Number of Operators: Full-time Part-time Manicurists

(Full-time means working over 16 hours per week. Part-time is 16 hours or fewer per week.)

3. Are all employees state-certified and are their licenses current? Yes No

4. Which of the following services do you provide:

Plastic surgery Body massage (other than face, scalp or hand) Removal of warts or moles Steam baths or saunas Skin tanning Hair straightening (other than by cold wave solution) Ear piercing* Hair removal by electrolysis, thermolysis or any Sculptured nail application* process using radio waves. Hair replacement procedures Tattooing or permanent make-up application

*If yes, complete reverse side of this supplement.

5. Do you cater specifically to the elderly, handicapped or children? Yes No

6. Do you offer babysitting service? Yes No

7. Do you have a play area for children or playground equipment on the premises? Yes No

8. Do you work off premises at hospitals, nursing homes, etc.? Yes No

9. How long do you retain records (name, address & date of service) of persons receiving permanentwaves or hair dyes?

10. Do you have retail sale of items other than hair care and nail care products? Yes No

11. Approximately what percentage of your total receipts is generated down from retail sales ofproducts? %

12. Are all combs, brushes and hair cutting implements sterilized before and after use? Yes No

13. How frequently do you change the germicidal solution?

14. Do you have a parking lot? Yes No

15. If yes, is it well lighted and maintained? Yes No

Completed by: Date:

ASB-6012 2/99 Safeco® and the Safeco logo are trademarks of Safeco Corporation.fpdffpdf

Sculptured Nails Supplemental Information

(Complete this section if porcelain or sculptured nails are applied.)

1. How many years has your shop offered nail services?

2. Have you ever had a related claim made against your shop? Yes No

3. What type of licensing is required of your manicurists/nail technicians?

4. Explain other hiring requirements.

5. Have you ever been fined by a state board of cosmetology? Yes No

6. What procedures/processes are used to sterilize tables, tools and equipment?

7. How frequently are tables, tools and equipment sterilized?

8. Do you perform cuticle nipping? Yes No

Ear Piercing Supplemental Information

(Complete this section if ear piercing is done.)

1. What hiring requirements apply to employees who perform ear piercing?

2. Please describe method(s) of ear piercing you use.

3. Do you or will you agree to perform piercing of any body parts other than ears? Yes No

4. What procedures/processes are used to sterilize tables, tools and equipment?

5. How frequently are tables, tools and equipment sterilized?

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