MED SPA LIABILITY INSURANCE APPLICATION
PART I.
GENERAL INFORMATION
1. Applicant Name:
2. Mailing Address:
3. Location Address(es):
4. County (parish) of each location:
5. Telephone Number(s)
Office:
Fax:
Email:
Questions on the Application? Call Jason Miller at 800-866-2682, Ext. 101
6. Contact Person:
