Application - Microneedling | Business Insurance for Canadian Beauty Care Professionals

Application for Microneedling

Once you click submit at the end of this form, one of our brokers will review the information. If we need any additional information, one of our brokers will contact you.

Contact Information

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Incorporated Name of Your Business (if NOT applicable, leave blank)

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Operating or Registered Name of Your Business (if NOT applicable, leave blank)

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Full Names of All Owners

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Contact Information

Salutation

Name*

First Name* Last Name*

Phone*

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Cell Phone

Email*

Enter Email* Confirm Email*

Details About Your Microneedling Services

List ALL the people providing Microneedling services who need to be insured on this policy:*

Name (First and Last)

Is Person an Employee or Independent Contractor

Number of Hours of Practical Hands-On Experience

Name of Training School where Certification was obtained

Is person Bloodborne Pathogen trained & certified?

Provide details of any prior liability claims against this person?

Please attach a photo of the Microneedling certification for all listed people (if you're not able to attach it now, a copy will be required prior to issuing coverage):

Drop files here or

Max. file size: 2 MB, Max. files: 5.

Do you have a business license permitting you to offer Microneedling services?*

Yes

No

Does your business have any outstanding health inspection infractions?*

Yes

No

If yes, provide details of infraction(s):*

Make(s) & Model(s) of Microneedling devices and needles or needle cartridges used?*

Make(s) & model(s) of Microneedling devices & needles or needle cartridges used:*

What is the maximum needle depth used (in mm)?*

Do you agree to perform Microneedling services only using sterilized, single-use disposable needles or needle cartridges?*

Yes

No

Do you agree to use a new needle or needle cartridge for each client and for each treatment session with the same client?*

Yes

No

Do you agree to dispose of needles and/or needle cartridges immediately after use in an approved sharps container?*

Yes

No

Do you agree to have each client sign a waiver indicating they understand the risks, side effects, outcomes and pre- and post-treatment care instructions for the Microneedling service?*

Yes

No

Do you agree to keep these client records for a minimum of 3 years?*

Yes

No

Do you agree to NOT provide Microneedling services to anyone under 18 years of age?*

Yes

No

Other Information

Comments

DECLARATION & PERSONAL INFORMATION CONSENT

Submitting this questionnaire allows us to confirm your eligibility, coverage and premium for your business. It does not obligate you to buy a policy - we will only issue a policy if you ask us to!

If you decide to buy a policy, then this application will attach to and form part of the insurance contract for which you are applying. Any applicant who gives false particulars or knowingly misrepresents or fails to disclose any fact in any part of this application will void the contract of insurance and may be subject to criminal and civil penalties.

Upon submission of this application, you declare that:

the person submitting this application is legally authorized to complete this application and enter into a contract of insurance on behalf of the person(s) or organization applying for coverage;
the information provided is true and correct and you hereby apply for a contract of insurance to be based upon the truth of these statements;
all machines used in your operation are CSA, ULC and/or UL approved;
the submission of this form is an application for insurance - no coverage is in effect until confirmed by PROtique.

I Agree to the Declaration and Consent Above*

First Name Last Name

Caution

Once the submit button is clicked, the application is sent to PROtique. If editing is required, please do so BEFORE clicking the submit button.

We never rent or sell our customers’, applicants’ or subscribers’ information.

Email

This field is for validation purposes and should be left unchanged.

Application for Microneedling

Application for Microneedling

Contact Information

Details About Your Microneedling Services

Other Information

Comments

DECLARATION & PERSONAL INFORMATION CONSENT

Caution

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