Anti-Aging Medical Spa Services

Anti-Aging Medical Spa Services

Complete the following fields to finalize your submission.
Name of Applicant*

First NameLast Name
Legal name of the business*
Principal business address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please attach a schedule of additional locations if needed
Phone Number*
Please enter a valid phone number.
Date established*

MonthDayYear
Date
Applicant's practice is a:*

Solo practitioner (unincorporated)Solo practitioner (incorporated)Professional AssociationPartnershipCorporation (non-profit)Corporation (for-profit)Other

Please state sources and amounts of total revenue:*

	Amount last 12 months	Estimated next 12 months
Fee for services
Other (explain below)
TOTAL Gross Revenue:

If other (explain)*

If applicant has a training school, complete the following:*

	Profession for which students are being trained	Max No. of students per session	Number of faculty per session	Qualification of faculty (e.g. MD RN)
-
-
-
-

What is the total number of faculty members?*
List all manufactured equipment and drugs used in the applicant's practice and purpose for which each is used:*

State approximate division of applicant's clients among the following categories:*

	%
Acupuncture
Massage Therapy
Ayurvedic Medicine
Medical Spa
Cosmetology-hair/nails/facial
Plastic Surgery
Dental
Research/Experimental
Dermatology
Surgical
Hormone Therapy
Weight Management

Other (please specify):*

Indicate the number of applicant's staff:*

	Employed	Contracted
Aesthetician
Electologist
Laser Technician
Massage Therapist
Medical Assistant
Nurse Practitioner
Physician
Physician Assistant
Registered Nurse

Other (specify)*
Are all the above individuals licensed in accordance with applicable state and federal regulations?*

YesNo
If No, please attach explanation.*
Do you require contracted staff to carry their own Professional Liability Insurance?*

YesNo
If Yes, do you maintain Certificates of Insurance to confirm such coverage?*

YesNo
Has the applicant or have any of the above employees:

(Attach detailed explanation for any 'Yes' answers)
ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital or professional association?*

YesNo
If Yes, please explain:
ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?*

YesNo
If Yes, please explain:
ever been treated for alcoholism or drug addiction?*

YesNo
If Yes, please explain:
ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered same?*

YesNo
If Yes, please explain:

Provide the following information for all procedures performed, include proof of training/certification, informed consent forms and client selection protocols:*

	Performed By:	Is training certificate attached? Yes/No	Is CV attached? Yes/No	Is client selection protocol attached? Yes/No	Is informed consent attached? Yes/No	Number of procedures per year?
Acne Blue Light Treatments
Botox Injections
Chemical peels
Colon Hydrotherapy
Cosmetology (hair/nails/facials)
Dermal fillers: Specify Type
Hormone Therapy (Specify Type and Method of Delivery)
Laser Hair Treatments
Laser Lipolysis / SmartLipo
Laser Skin Treatments: Specify Type
Massage Therapy
Mesotherapy
Microdermabrasion
Micropigmentation
Sclerotherapy
Tattoo Removal
Tooth Whitening
Waxing

If Other, describe:
Are there any procedures performed by a physician or dentist?*

YesNo
If Yes, does the physician(s) or dentist(s) have Medical Malpractice Liability Insurance for this activity?*

YesNo
Is the applicant currently insured under a commercial general liability policy including products and completed operations coverage?*

YesNo
Has any similar insurance ever been declined or cancelled?*

YesNo
Does any person to be insured have knowledge or information of any act, error or omission which might reasonably be expected to give rise to claim against him/her?*

YesNo
If Yes, please attach complete details including a description of the incident(s)
It is understood and agreed that with respect to questions 14 and 15, that if such knowledge or information exists any claim or action arising there from is excluded from this proposed coverage.

Notice to New York applicants: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material thereto, commits a fraudulent insurance act, which is a crime

The applicant hereby acknowledges that he/she/it is aware that the limit of liability shall be reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the Insurer shall not be liable for the costs of legal defense or for the amount of any judgement or settlement to the extent that such exceeds the limit of liability.

The applicant further acknoledges that he/she/it is aware that legal defense costs that are incurred shall be applied against the deductible amount.

I DECLARE that, after inquiry, the above statements and particulars are true and I have not suppressed or misstated any material fact and that I agree that this application shall be the basis of the contract with the Underwriters.
Name of applicant*

First NameLast Name
Signature of person authorized to execute on behalf of the applicant:*

Clear
Date*

MonthDayYear
Date
This application form duly completed, together with any supplementary information, must be signed in ink or by electronic signature by the person indicated.

Signing of this form does not bind the applicant or the Underwriters to complete this insurance.

A copy of this application should be retained for your records.
Should be Empty: