Page 2
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User Details:
Name
*
Street
*
Suburb / Town
*
State
*
-- Please Select
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Postcode
*
Phone
*
Email
*
Website
*
Indicates mandatory field
Page 3
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Staff and Locations:
Number of Qualified Staff
*
Do you operate from more than one salon/location?
*
Yes
No
Answer is required
If yes, how many additional locations?
Locations is required
*
Indicates mandatory field
Activity Indication:
Hairdressing
*
Yes
No
Beautician
*
Yes
No
Manicurist / Pedicurist
*
Yes
No
Facials: Peels
*
Yes
No
Facials: No Peels
*
Yes
No
Facials: Microdermabrasion
*
Yes
No
Waxing
*
Yes
No
Body Wraps
*
Yes
No
Massage
*
Yes
No
Electrolysis
*
Yes
No
General Make-Up
*
including Theatrical/Film, etc
Yes
No
Semi Permanent Make-Up
*
Yes
No
Camouflage
*
Yes
No
Spray Tanning
*
Yes
No
Solarium
*
Yes
No
Answer is required
If yes, how many units?
Units is required
Facial Piercing
*
Yes
No
Body Piercing: Above the Navel
*
Yes
No
Body Piercing: Below the Navel
*
Yes
No
I.P.L. Treatment
*
Yes
No
Answer is required
If yes, how many units?
Units is required
Photo Rejuvenation
*
Yes
No
Other
Please specify in general
*
Indicates mandatory field
Page 4
of 4
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Current Insurance:
Current Insurer
What type of Business Insurance do you currently hold?
Professional Indemnity
*
Public and Product Liability
*
Property Insurance
*
Yes
No
Yes
No
Yes
No
Expiry Month
None
January
February
March
April
May
June
July
August
September
October
November
December
Estimate of Current Premium paid
Do you use a Broker?
*
Yes
No
Answer is required
If yes, what is the name of the Broking Firm?
Broker Firm is required
*
Indicates mandatory field