MEDI-SPA APPLICATION Applicant Name: Business Name: Email Address: Mailing Address: City: Business Address #1: City: Type of Facility? Business Address #2: City: Type of Facility?

Phone: Website: State:

Zip:

State:

Zip:

Square Feet

State:

Zip:

Square Feet

Business operated as:  Corporation  LLC  LLP  Partnership  Individual  Independent Contractor Business operated as Medi-spa?  Yes  No If not, other: Annual gross receipts from all operations? Total number of procedures performed annually? How long in business?

Do all professionals have licenses?  Yes  No

Products liability needed for products sold by you?  Yes  No Gross receipts (excluding private label) Do you private label products for sale  Yes  No This requires a separate application Do you want to include General Liability  Yes  No If yes, provide Square Feet above  If No what company insures your General Liability? _______________ Will you have other operations you do not wish to cover on this policy?

Yes

No

If yes please provide details: Do you have:

I.

Saunas/Steam Rooms? Soaking Pools? Showers?

Yes Yes Yes

No If yes, #______ No If yes, #______ No If yes, #______

BEAUTY SERVICES

Category – Pick the BEST ONE for each technician based on definitions below. Beauticians Massage Aesthetician Medical Aesthetician, do you use Levulan? Yes No TOTAL NUMBER OF TECHNICIANS

Number to be Insured

_______________

Are any of the technicians above covered for other medispa services on this policy? If so, list technician names: ___________________________________________________________________________________________________________ DEFINITIONS: * BEAUTICIANS: Hair, Nails, Eyelash & Brow Enhancements, Waxing, Threading, Topical Makeup Application * MASSAGE: Massage, Body Wraps, Endermologie, Reiki * AESTHETICIANS: All Beautician services AND Facials, Aesthetic Peels, Body Wraps, Massage, Electrology, Microdermabrasion, Ear Piercing, Airbrush Tanning, Ear Candling, Aesthetic Body Treatments * MEDICAL AESTHETICIANS: All Beautician and Aesthetician Services, AND Needling/MCA, Medical Grade Peels, LED/Microcurrent, Non-invasive Ultrasound, Radio Frequency, Dermaplaning, Ear Candling 1.1 Have you ever been trained in massage? Yes No 1.2 Do you use a consent form for medical peels? Yes No 1.3 Do you want coverage for sexual abuse? Yes No (If yes choose limit) $50,000 Aggregate/$25,000 Claim $100,000 Aggregate/$50,000 Claim Other Limit: ____________________________________

$200,000 Aggregate/$100,000 Claim

II.

TEETH WHITENING/HAIR STIMULATION

2.1

Total Number of Units to be covered?

2.2a

Do you provide customers with home whitening products?

Yes

No

2.2b

If yes, do you provide written instructions for home use?

Yes

No

2.3

Have all operators been trained in LED Hair Stimulation?

Yes

No

If this section does not apply, check here

On behalf of all LED Teeth Whitening technicians, I understand: 1. Every client must sign a consent & dental history form. No coverage will apply if there is not a signed form on file. 2. I understand there is no coverage for any prescription anesthetic use. 3. I understand if I treat pregnant women a written doctor’s approval will be on file. On behalf of all Hair Stimulation technicians, I understand: 1. Coverage is excluded for any guarantees of hair growth 2. Coverage is available only for units designed specifically for hair stimulation 3. I understand for coverage to apply only trained technicians will turn on or operate the Device. 4. I understand a signed consent and medical history form must be on file for coverage to apply Signed

III. 3.1

Dated:

LASER/IPL/RADIO FREQUENCY SERVICES

If this section does not apply, check here

Do you have everyone sign a consent form & complete a medical history form? I am submitting my own forms for approval

Yes

No

I will use PPIB Approved Forms

3.2

Do you provide goggles or eye shields for all laser/IPL work on faces?

Yes

3.3

Are you in compliance with all FDA and state laws as to use of lasers/IPLs/Light devices?

Yes

No No

On behalf of all laser operators endorsed herein, I understand: 1.

The Fitzpatrick Scale. I will not be insured to work on Skin Types V & VI unless I have 6 months of experience with Lasers/IPLs.

2.

It is warranted that for Class III & IV devices goggles must be worn by all people in the room at all times the laser is in use. All reflective surfaces will be covered.

3.

Every client must sign a consent & medical history form. No coverage will apply if there is not a signed form on file.

4.

For Class IV laser use, the room door will stay locked at all times the laser is in use or a sign must be posted on door: LASER IN USE, DO NOT ENTER

5.

I understand there is no coverage for EMLA anesthetic use.

6.

No insurance will be offered for the following treatments: i. any raised tissue with its own blood supply (such as moles), ii. Skin that is ulcerated, broken (not intact), blistered or has open sores; iii. Bulging veins,veins or cherry hemangiomas over 3.0 millimeters.

7.

I understand coverage for laser hair removal work on individuals under the age of 14 is excluded

8.

I understand all new Laser/IPL technicians must have six months experience or thirty hours training to be eligible for laser/IPL coverages

9.

I AM USING ONLY CLASS III AND IV DEVICES THAT HAVE BEEN APPROVED FOR SALE BY THE FDA.

Signature of Applicant/Title

Dated

We prefer you use the carrier approved consent, medical history and aftercare forms that are available at www.medispa-ins.com No insurance binding can be considered until all forms are approved by PPIB

OPERATOR INFORMATION (Laser/IPL/Radio Frequency) OPERATOR TO BE NAMED: 1.

Licenses held & license numbers:

2.

How long have they been working with these devices?

3

What services do you offer:

Laser Hair removal

Veins (up to 3.0mm, spider veins) spots

Smoking Cessation

Photo Rejuvenation

Nonablative wrinkle reduction

Laser Acupuncture Weight Loss

Cellulite Reduction

Laser allergy services

4.

What other services, not listed above, do you offer?

5.

Education in light source equipment: List all information as requested Date

Tattoo removal

Class Title

Rosacea

Skin Tag Removal

Nail/Toe Fungus

Age/sun

Laser acupuncture

Number of Hours

OPERATOR INFORMATION (Laser/IPL/Radio Frequency) OPERATOR TO BE NAMED: 1.

Licenses held & license numbers:

2.

How long have they been working with these devices?

3

What services do you offer:

Laser Hair removal

Veins (up to 3.0mm, spider veins) spots

Smoking Cessation

Photo Rejuvenation

Nonablative wrinkle reduction

Laser Acupuncture Weight Loss

Cellulite Reduction

Laser allergy services

4.

What other services, not listed above, do you offer?

5.

Education in light source equipment: List all information as requested Date

Tattoo removal

Class Title

Rosacea

Skin Tag Removal

Nail/Toe Fungus

Age/sun

Laser acupuncture

Number of Hours

OPERATOR INFORMATION (Laser/IPL/Radio Frequency) OPERATOR TO BE NAMED: 1.

Licenses held & license numbers:

2.

How long have they been working with these devices?

3

What services do you offer:

Laser Hair removal

Veins (up to 3.0mm, spider veins) spots

Smoking Cessation

Photo Rejuvenation

Nonablative wrinkle reduction

Laser Acupuncture Weight Loss

What other services, not listed above, do you offer?

5.

Education in light source equipment: List all information as requested Class Title

Photocopy this page if covering more than 3 people

Cellulite Reduction

Laser allergy services

4.

Date

Tattoo removal

Rosacea

Skin Tag Removal

Nail/Toe Fungus Laser acupuncture

Number of Hours

Age/sun

IV.

MEDICAL DIRECTOR

4.1 4.2

Is there a medical doctor on your staff? Yes Give name and degree of your supporting doctor:

No

Do they work out of your office?

4.3

Do you want to cover the doctor as medical director on the policy?

4.4

If yes, indicate any claims they have had in their medical career:

4.5 4.6

Is the doctor a medical director for other facilities? If so, should coverage be extended? Number of facilities: For what services:

V. BOTOX/DERMAL FILLER OPERATOR 5.1 5.2

Yes Yes

No No

Yes Yes

No No

If this section does not apply, check here

Are you in compliance with all AMA and state laws as to use of Botox & Fillers? Do you have everyone sign a consent & medical history form?

Yes Yes

No No

On behalf of all Injectable operators, I understand: 1. I will only have coverage in specified facilities unless the no location limit endorsement is purchased. 2. 3.

I will only buy Botox in the United States from Allergan or from an approved Allergan wholesaler or Dysport from Medicis or an approved Medicis wholesaler or Xeomin from Merz or an approved wholesaler No insurance will be offered for any injectable work unless applied for herein.

4.

Botox coverage is only provided for work on patients over 18.

5.

Every client must sign a consent form and no coverage will apply if there is not a signed form on file. We prefer you use the carrier approved consent, medical history and aftercare forms that are available at www.medispa-ins.com

6.

No coverage is provided for work on pregnant or nursing women.

7.

There is no coverage for prescription medications except for anesthetics used with dermal fillers and/or anti-viral medication prescribed for one of the procedures, unless endorsed. I understand each technician must have training or 6 months experience to be eligible for injectable coverage

8.

Signature of Applicant/Title

Technician

Dated

Degree or License Type

Yrs of Experience

1. 2. 3.

Check All To Be Covered:

Botox/ Dysport/Xeomin If yes do you perform any of the following? Hyperhydrosis * Masseters* Platysmal Bands* House Parties* Injectables/Others: Restylane Sculptra Juvederm (Ultra/Voluma) Perlane Radiesse Belotero Selphyl /PRP* Injectables on Hands* Carboxy Therapy* Other:________ *Additional Premium May Apply

VI.

PLATELET RICH PLASMA (PRP)

If this section does not apply, check here

6.1 Name & Degree of Operator. Years of Experience 6.2 Do you perform cosmetic services with PRP? Yes No Check all that apply: Filler Vampire Face Lift Breasts Hair Stimulation Vitiligo Other: (Please List) __________________________________________________________ 6.3 Do you perform Therapeutic Treatments with PRP? Yes No If yes check all that apply: Joint Pain Reduction Wound Healing Prolotherapy (Describe: ___________________________________________________________________) Priapus VII.

O Shots

Other: ______________________________________________________________

MESOTHERAPY SERVICES

If this section does not apply, check here

7.1 Do you have everyone sign a consent & medical history form? 7.2 Do you give everyone aftercare?

Yes Yes

No No

Please provide copies

On behalf of all Mesotherapy technicians, I understand: 1. All technicians must have training or six months experience to be eligible for Mesotherapy coverage 2. 3.

All products used must be purchased from licensed compounding pharmacies (Note only ingredients approved by the company will be covered) If I am using between 20ccs and 40ccs in one visit, that the clients must stay and relax and sign the dizziness section on the Mesotherapy consent form. _________ (Initial in agreement)

4.

No coverage is provided for work on pregnant or nursing women.

5.

That Mesotherapy injections will only be offered for fat reduction, cellulite and wrinkles? _____ (Initial)

6.

Every client must sign a consent form and no coverage will apply if there is not a signed form on file. We prefer you use the carrier approved consent, medical history and aftercare forms that are available at www.medispa-ins.com Signature of Applicant/Title

Technician

Dated

Degree or License Type

Yrs of Experience

1. 2. 3.

VIII.

SCLEROTHERAPY

If this section does not apply, check here

8.1 Do you have everyone sign a consent & medical history form? 8.2 Do you give everyone aftercare?

Yes Yes

No No

On behalf of all Sclerotherapy operators, I understand: 1. There is no coverage for work on veins over 3.0mm in diameter unless endorsed herein. 2. Each technician must have specific training to be eligible for coverage 3. Coverage is only available for products that are used exclusively for the treatment of spider or varicose veins 4. Every client must sign a consent form and no coverage will apply if there is not a signed form on file. We prefer you use the carrier approved consent, medical history and aftercare forms that are available at www.medispa-ins.com 5. No coverage is provided for work on pregnant or nursing women. Signature of Applicant/Title

Technician 1. 2. 3.

Dated

Degree or License Type

Yrs of Experience

IX. WEIGHT LOSS & APPETITE SUPPRESSANTS 9.1

If this section does not apply, check here

OPERATOR(S) TO BE NAMED:

9.2 Licenses you hold & license numbers: 9.3 Are you in compliance with all FDA and state laws as to weight loss services? 9.4 Wellness Analysis? 9.5 Do you provide Nutritional/Diet Consulting? PROFESSIONAL INFORMATION

Yes Yes Yes

No No No

9.5 9.5

How long have you been performing weight loss services? How many approximate patients have you treated for weight loss?

9.6

What is your gross annual income from weight loss services?

9.7

Education in weight loss: List all classes and include certificates of completion and your CV Date Class Title Number of Hours

9.8 9.9

9.10

Do you provide prescriptions for weight loss? Yes No What products do you use for weight loss? HCG Phentermine Lipotropics Phendimetrazine Didrex Tenuate/Diethylpropian Belviq Qsymia Orlistat Other (please describe) What other weight loss services do you provide? Must list everything for coverage to be considered:

We prefer you use the carrier approved consent and medical history forms that are available at www.medispa-ins.com I will use PPIB forms: I am submitting my own forms for approval:

Signed: Signed:

Title: Title:

No insurance binding can be considered until all forms are approved by PPIB X. SUPPLEMENTS/VITAMINS/HORMONES/INJECTIONS

10.1

10.2

10.3 10.4 10.5 10.6

Name & Degree of Operator: Name & Degree of Operator: Name & Degree of Operator: Vitamins & Supplements you are providing B12 B Complex Chromium Glycine Other (please describe)

If this section does not apply, check here

Amino Acids

Vitamin C

Glutathione

Hormone services you are providing? Male treatments? Female treatments? Do you provide vitamins/supplements/hormones? Yes No Ingestible Implantable Injectable Do you offer any of the following services? Flu Shots Chelation Therapy IV Therapy Blood Draws Immunotherapy If yes, describe : Do you provide consent forms for the above? Yes No

We prefer you use the carrier approved consent and medical history forms that are available at www.medispa-ins.com I will have everyone sign a consent form:

Signed:

Title:

No insurance binding can be considered until all forms are approved by PPIB

XI.

DIRECT PATIENT CARE/PHYSICIAN

If this section does not apply, check here

11.1

Name of Physician(s):

11.2

Do you offer Direct Patient Care for services not otherwise listed on this application? If Yes, please describe services: Do you offer prescriptions not otherwise listed herein?

Yes

Yes

No

No

MEDICAL ASSISTANTS

If Yes, please list categories:

XII.

Technician

Services you will be assisting with

1. 2. 3. 4. 5. COSMETIC MEDICAL PROCEDURES

If this section does not apply, check here

Mini Tummy Tucks 12.1a DOCTOR TO BE NAMED: 12.1b Licenses you hold & license numbers: 12.1c Do you remove the belly button?

Yes

No

12.1d What type of anesthesia is used? 12.1e Provide Training & Experience: _________________________________________________________________________ Blepharoplasty 12.2a DOCTOR TO BE NAMED: 12.2b Licenses you hold & license numbers: 12.2c Do you perform: Lower Blepharoplasty or

Upper Blepharoplasty?

12.2d What type of anesthesia is used: 12.2e Provide Training & Experience: _________________________________________________________________________ Silhouette Face Lift 12.3a DOCTOR TO BE NAMED: 12.3b Licenses you hold & license numbers: 12.3c What type of anesthesia is used: 12.3d Provide Training & Experience: _________________________________________________________________________ Hair Transplant 12.4a DOCTOR TO BE NAMED: 12.4b Licenses you hold & license numbers: 12.4c What type of Hair Transplant Services are provided?: Neograft Fue Strip Other___________________ 12.4d Provide Training & Experience: _________________________________________________________________________ Do you provide Consent forms for above services?

Yes

No

Every client must sign a consent form and no coverage will apply if there is not a signed form on file. We prefer you use the carrier approved consent, medical history and aftercare forms that are available at www.medispa-ins.com Signature of Applicant/Title

Dated

XIII. LASER/ULTRASOUND ASSISTED LIPOLYSIS/TUMESCENT LIPOSUCTION If this section does not apply, check here 13.1 13.2 13.3 13.4 13.5 13.6

DOCTOR OR P.A. TO BE NAMED: ___________________________________________________________ Licenses you hold & license numbers: ___________________________________________________________ How long have you been providing Invasive Lipolysis services? Device being used for Lipolysis ________________________________________________________________ How long have you been providing Tumescent Liposuction services? _________________________________ Do you provide additional liposuction services that are not Tumescent? Yes No If yes, please describe:_____________________________________________________________________

13.7

Education in Lipolysis/Liposuction: List all classes and include certificates of completion and your CV Date Class Title

13.8

What other Lipolysis or Liposuction services do you provide?

FAT TRANSFER

Tickle Lipo

Other

If this section does not apply, check here

13.9 13.9a

Do you provide fat transfer injections? Method of Fat Removal:

Yes

No

13.9b 13.9c 13.9d

In what areas do you re-inject: If in the breast, do you use the Brava System or something similar? Yes No Do you have everyone sign a consent form and complete a medical history form?

Yes

No

We must receive a copy of the form(s) you use. Use of these forms is warranted on the policy.

I will have everyone sign a consent form. I will only reinject fat into the person that is was removed from.

XV.

ADDITIONAL OPERATORS/SERVICES PROVIDED (Additional applications may be required)

OTHER SERVICES

Signed______________________________________________________Date:____________________________

1.

Technician

Services Provided

Yrs of Experience

2. 3.

Removal of Warts Removal of Moles How are they removed?

Category Permanent Makeup Techs Personal Trainers Colon Hydrotherapy Techs

Acupuncture Hypnosis Acne Subcision

Oxygen Devices # of Units Flotation Devices # of Units Hyperbaric Oxygen Chambers # of Units Salt Caves/Rooms # of Rooms UV Tanning # of Units Foot Detox # of Units

Number to Insure _________ _________ _________

Optional Coverages – Check Any Coverage Box below for which you would like a Quote Defense Outside the Limits

Yes

No

HIPAA Reimbursement

Yes

No

Communicable Disease

Yes

No

Property Coverage

Yes

No

XVI- HISTORY: NOTE: All questions must be answered. Failure to disclose claims history could invalidate coverage. 16.1

Do you currently have insurance coverage?  Yes  No If yes, indicate the following: Insurer Policy # Liability Limits Premium

Exp. Date

If claims made, most recent retroactive date:  Yes  No

16.2

Have you ever had professional liability insured refused, declined, cancelled or accepted on special terms? If yes, provide details on a separate sheet

16.3

Has any liability suit, arbitration or other claim proceeding been brought against you, your business or any applicant for any alleged malpractice? If yes, provide details on a separate sheet

 Yes  No

16.4

Do you, or any applicant, have knowledge of an event, circumstance or occurrence prior to the effective date of the proposed policy, or do you foresee that a claim may be brought as a result of said event, circumstance or occurrence? If yes, describe details on a separate sheet

 Yes  No

16.5

Has any applicant’s license or certification ever been investigated, limited, revoked, suspended, refused, cancelled or voluntarily surrendered by, or to, any state or federal licensing board or regulatory agency? If yes, provide details on a separate sheet

 Yes  No

16.6

Have you ever or any applicant ever been charged or convicted of a criminal offense? If yes, provide details on a separate sheet

 Yes  No

4.2

I understand and agree this Application and any supplements attached hereto will be relied upon for issuance of any policy. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the company, result in the voiding of the insurance issued in reliance on this application and/or denial of claims under any policy issued. I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to engage in the activities of my business including authorization to every person or entity, public or private, to release to all Lloyd’s of London participating syndicates, any documents, records or other information bearing upon the foregoing. I understand and agree these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law. Furthermore, I understand that the policy applied for will apply only to CLAIMS FIRST MADE AND REPORTED to the Company in writing within the period of coverage shown on the certificate of insurance issued with the policy or certificate on the date the policy is canceled or terminated, whichever comes first or as otherwise provided by the policy. I understand this insurance is being provided through a surplus lines company and the insurer may not be subject to all the insurance laws and rules in my state and the risk is not protected by the State Insurance Insolvency Fund.

THIS APPLICATION MUST BE SIGNED BY APPLICANT WITHIN 30 DAYS OF BINDING. SIGNING THIS FORM DOES NOT BIND THE COMPANY TO COMPLETE THE INSURANCE. COVERAGE BECOMES EFFECTIVE WHEN ACCEPTED BY THE INSURANCE COMPANY

APPLICANT SIGNATURE

DATE

TITLE

REQUESTED EFFECTIVE DATE

Can we email you your policy (usually within 2-3 weeks)

Yes

LIABILITY LIMIT REQUESTED

No ______________________________@______________

One box below must be checked:

 I ELECT TO PURCHASE TERRORISM COVERAGE AT AN ADDITIONAL PREMIUM  I DO NOT ELECT TO PURCHASE TERRORISM COVERAGE AT AN ADDITIONAL PREMIUM

ADDITIONAL INSURED: Certificate Holder (Landlord or Lessor) If necessary, add other names on separate paper. NAME: ADDRESS: