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MediSpa Professional Liability Insurance
Same Day Quote & Issue |
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Call
Toll Free 1-800-874-9191
Fax
480-452-0593
www.EQGroup.com |
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For no-obligation
Medi-Spa Liability Insurance quote, please complete
the following form
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| Insured Name |
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| Address
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| Address 2 |
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| City |
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| State |
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| Zip |
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| Entity Type |
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| Name &
Title of Principals |
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| Year Established |
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Primary
Contact |
| Contact Name |
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| E-mail |
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Business Phone |
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(Area + Number) |
| Fax |
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(Area + Number) |
| Cell phone |
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(Area + Number) |
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Website |
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Business Information |
| Desired
Policy Effective Date? |
| Start |
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Liability Limit |
Per Occurrence |
| Number
of locations |
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Schedule of Service - Complete only sections for
which coverage is desired
Coverage only offered for professional offices, Medi-Spas,
Salons or Medical Facilities |
Laser / IPL
Professional Liability
Hair Removal, Rosacea, Age / Sun Spots, Wrinkle
Reduction, Veins Cellulite, Acne, Photo Facials |
| Include
Tattoo Removal? |
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| Name of
Non Doctor Technicians |
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| Name of
Doctor Technicians |
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Botox / Dermal Filler
Procedures |
| Name &
Degree of Technicians |
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Sclerotherapy
Procedures |
| Name &
Degree of Technicians |
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Aesthetic Facial Peel
Procedures |
| Include
Microderm Abrasion? |
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| Include
Wax Removal? |
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| Name &
Degree of Technicians |
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Medical Grade Peel
Procedures |
| Name of
Technicians |
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Mesotherapy /
Lipodissolve Procedures |
| Name &
Degree of Technicians |
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Laser Lipolysis
Procedures |
| Name &
Degree of Technicians |
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Permanent Makeup
Procedures |
| Name of
Technicians |
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Other Procedures |
LEDs /
Microcurrent - (No Hair Removal)
Number of Techs Performing Service |
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LEDs /
Teeth Whitening
Number of Techs Performing Service |
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Policy Options
— in addition to general
liability do you require? : |
| Additional Insureds added to policy? |
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| Miscellaneous equipment coverage? |
$ <- if yes, enter total
replacement value |
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General Underwriting Questions |
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| GQ1.
Are you in compliance with all city, county & state
ordinances? |
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| GQ2. Do
you use a release / client information for every client? |
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| GQ3. Any
losses in past 3 years? |
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How did you hear about us? |
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Comments or Special
Instructions |
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| AFIG
Producer - Please enter Name & Number |
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Insurance Definitions |