MedSpa Quote - Marker Insurance
19380
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MedSpa Quote

Business Owners Questionnaire


Name Insured:

Address:

Telephone:

Email:

Description of Business:

Years in Business:

Tax ID Number:

Medical Director:

Loss Information:

Gross Sales:

 

Med Spa Operations

ACUPUNCTURE

Current # of Procedures Annually:

BOTOX

Current # of Procedures Annually:

CHELATION THERAPY

Specify Type:

CHEMICAL PEELS

Specify Type:

DAY SPA ACTIVITIES: WAXING, WRAPS, DERMOSONIC, EXFOLIATIONS, FACIALS, HAIR CARE, LASH EXTENSIONS, MAKE-UP APPLICATIONS, NAILS, REFLEXOLOGY, TANNING

Current # of Procedures Annually:

HAIR TRANSPLANT

Specify Type:

HERBAL OR VITAMIN SUPPLEMENTS OR REMEDIES

Current # of Procedures Annually:

HORMONE THERAPY/VITAMIN INJECTIONS

Specify Type & Delivery Method:

INJECTIONS/FILLERS, RESTYLANE AND JUVEDERM

Current # of Procedures Annually:

KYBELLA FOR RECOMMENDED USES ONLY

Current # of Procedures Annually:

LASER HAIR REMOVAL/ELECTROLYSIS

Current # of Procedures Annually:

LASER LIPOSUCTION (SMART LIPO)

Current # of Procedures Annually:

LASER SKIN TIGHTENING: VELASMOOTH (CELLULITE TREATMENT WITH RADIO FREQUENCY), THERMAGE, ENDERMOLOGIE

Current # of Procedures Annually:

LASER SKIN TREATMENT: TITAN, GENESIS, FRAXEL

Current # of Procedures Annually:

LIPOINJECTION/FAT TRANSFER

Current # of Procedures Annually:

LIPOSUCTION (REGULAR)

Current # of Procedures Annually:

LIPOSUCTION (TUMESCENT)

Current # of Procedures Annually:

MASSAGE

Current # of Procedures Annually:

MESOTHERAPY/LIPODISSOLVE

Specify Type:

MICRODERMABRASION

Current # of Procedures Annually:

MICROPIGMENTATION (PERMANENT MAKEUP)

Current # of Procedures Annually:

MINI FACELIFT

Current # of Procedures Annually:

PHOTO THERAPY: LEVULAN, PHOTO REJUVENATION (RPL), FOTO FACIALS

Current # of Procedures Annually:

PRP/PROLOTHERAPY

Specify Type & Where Used:

RADIOFREQUENCY FACE LIFT PROCEDURES

Current # of Procedures Annually:

SKIN TAG REMOVAL

Current # of Procedures Annually:

SCLEROTHERAPY

Current # of Procedures Annually:

TATTOO REMOVAL

Specify Type:

WEIGHT CONTROL MEDICATIONS

Specify Type:

OTHER

Describe Procedure Type:

OTHER

Describe Procedure Type:

OTHER

Describe Procedure Type:
OTHER

Describe Procedure Type:

 

Medical Staff

 

Physician Name:

Physician Name:

Physician Name:

Medical Professional (RN, Nurse, PA, SA) Name:

Medical Professional (RN, Nurse, PA, SA) Name:

Medical Professional (RN, Nurse, PA, SA) Name:

Medical Professional (RN, Nurse, PA, SA) Name:

 

Property Information

 

Building

Square Feet:

Construction:

 

Updates

Roof:
Electric:

Alarm:

 

Other occupants in building:

Shutters Protection:

Building/Additional & Alterations Limit:

Content Limit:

Additional Coverage:

Additional Attachments: