MED SPA LIABILITY INSURANCE APPLICATION
PART I.  GENERAL INFORMATION
1.  Company name:
2.  Mailing address:
3. How many locations do you have?
5.  Telephone Number(s) 
Office:
Fax:
Email:
Questions on the Application?  Call David Dickie at 800-866-2682, Ext. 113
6.  Contact Person: 
PART II.  SCHEDULE OF SERVICES
7.  How many landlords need proof of insurance?
Laser / IPL Hair Removal

Name of Non Doctors









Laser / IPL Professional (hair removal, rosacea, age/sun spots, wrinkle reduction, veins, cellulite, acne, photo facials)

Include Tatoo Removal Coverage?
Botox / Dermal Fillers
Name & Degree of Technician:
4. How many square feet of space (all locations in total)?
Mesotherapy / Lipodissolve
Name & Degree of Technician
Sclerotherapy
Name & Degree of Technician
Medical Grade Peels
Name of Technician
Aesthetic Facials, Peels
Include Microdermabrasion?
Include Wax Removal?
Name of Technician:
Laser Lipolysis (List Name & Degree)
Permanent Makeup
Doctor Supervisor To Be Insured?
LEDs / Microcurrent (no hair removal)
Number Performing Service:

LED Teeth Whitening
Number of Units:
What Limit of Insurance Would You Like Quoted?




List Other Services & Name of Technicians:
Name of Doctor Operators
Name of Non Doctors
Name of Doctor Operators
(Common limits are $1,000,000/$3,000,000, $500,000/$1,000,000, $300,000/$600,000 or $100,000/$300,000, where the first number is the per occurrence limit and the second number is the aggregate limit)
PART III:  OTHER EXPOSURES
Please note the number of each:
Please note the number of each:
City, State and Zip:
Annual Revenue?
Federal Tax ID Number:
PART IV: INSURANCE COVERAGE
Do you Have Insurance Coverage Currently?
Insurance Company:
Renewal Date:
YesNo
YesNo
YesNo
YesNo
Hydrotherapy Tubs
Steam Rooms
Saunas
Whirlpools
Jacuzzis
Tanning Beds/Booths
Toning Machines
Aqua Massage
Exercise Equipment
Showers
YesNo