MedSpa Quote - Marker Insurance

19380

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MedSpa Quote

Business Owners Questionnaire

Business Name (dba):

Street Address:

City:

Zip Code:

State:

County:

Telephone:

Contact:

Email:

Fax:

Description of Business:

Years in Business:

Number of Employees:

Tax ID Number:

Medical Director:

Loss Information:

Gross Sales:

Payroll:

Med Spa Operations

ACUPUNCTURE

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing: [select professional-1 include_blank "Aesthetician" "PA" "NP" P"hysician"]

BOTOX

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

CHELATION THERAPY

Specify Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

CHEMICAL PEELS

Specify Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

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

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

HAIR TRANSPLANT

Specify Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

HERBAL OR VITAMIN SUPPLEMENTS OR REMEDIES OR IV and Gluteal injection

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

HORMONE THERAPY/VITAMIN INJECTIONS

Specify Type & Delivery Method:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

INJECTIONS/FILLERS, RESTYLANE AND JUVEDERM

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

KYBELLA FOR RECOMMENDED USES ONLY

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

LASER HAIR REMOVAL/ELECTROLYSIS

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

LASER LIPOSUCTION (SMART LIPO)

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

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

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

LASER SKIN TREATMENT: TITAN, GENESIS, FRAXEL

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

LIPOINJECTION/FAT TRANSFER

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

LIPOSUCTION (REGULAR)

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

LIPOSUCTION (TUMESCENT)

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

MASSAGE

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

MESOTHERAPY/LIPODISSOLVE

Specify Type:

Projected # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

MICRODERMABRASION

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

MICROPIGMENTATION (PERMANENT MAKEUP)

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

MINI FACELIFT

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

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

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

PRP/PROLOTHERAPY

Specify Type & Where Used:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

RADIOFREQUENCY FACE LIFT PROCEDURES

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

SKIN TAG REMOVAL

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

SCLEROTHERAPY

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

TATTOO REMOVAL

Specify Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

WEIGHT CONTROL MEDICATIONS

Specify Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

OTHER

Describe Procedure Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

OTHER

Describe Procedure Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

OTHER

Describe Procedure Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

OTHER

Describe Procedure Type:

Current # of Procedures Annually:

Projected # of Procedures Annually:

Professional Performing:

Medical Staff

Physician Name:

Primary Specialty:

Hours Worked:

Physician Name:

Primary Specialty:

Hours Worked:

Physician Name:

Primary Specialty:

Hours Worked:

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

Primary Specialty:

Hours Worked:

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

Primary Specialty:

Hours Worked:

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

Primary Specialty:

Hours Worked:

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

Primary Specialty:

Hours Worked:

Property Information

Building

Square Feet:

Number of Stories:

Construction:

Year Built:

Updates

Roof:

Plumbing:

Electric:

Heating:

Alarm:

Other occupants in building:

Shutters Protection:

Building/Additional & Alterations Limit:

Deductible:

Content Limit:

Deductible:

Additional Coverage:

Additional Attachments:

Disclaimer: Insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise.No binder, insurance policy,change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly by a licensed agent.

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