Med Spa Liability Insurance

MED SPA LIABILITY INSURANCE APPLICATION

2101 Lockhill Selma Road, Suite 210

San Antonio, TX 78213

Voice: 800-866-2682

Fax: 866-847-7232

PART I. GENERAL INFORMATION

1. Applicant name:

2. Mailing address:

3. How many locations do you work out of?

5. Telephone Number(s)

Office:

Fax:

Email:

Please click only once

Questions on the Application? Call Jason Miller at 800-866-2682, Ext. 101

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: