PL & GL for Medi Spas, Beauty Salons, Gyms

MEDI-SPA APPLICATION
Do you have: Saunas/Steam Rooms? Yes No If yes, # to Insure:______
Soaking Pools? Yes No If yes, # to Insure:______
Showers? Yes No If yes, # to Insure:______
I. BEAUTY SERVICES
TOTAL NUMBER OF OPERATORS _______________
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, 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 If applying for medical aesthetician, do you use Levulan? Yes No
1.3 Do you use a consent form for medical peels? Yes No
1.4 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 $200,000 Aggregate/$100,000 Claim
Applicant Name: Phone:
Business Name:
Email Address: Website:
Mailing Address:
City: State: Zip:
Business Address #1:
City: State: Zip: Square Feet
Type of Facility?
Business Address #2:
City: State: Zip: Square Feet
Type of Facility?
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
Will you have other operations you do not wish to cover on this policy? Yes No
If yes please provide details:
Category – Pick the best ONE for each technician based on definitions below. Number to be Insured
Beauticians
Massage
Aesthetician
Medical Aesthetician

FOLLOWING SERVICES REQUIRE SEPARATE APPLICATIONS IF COVERAGE IS NEEDED
Category Number to Insure Category Number to Insure
UV Tanning Units _________ Foot Detox _________
Permanent Makeup _________ Property Coverage Yes No
II. MEDICAL DIRECTOR
2.1 Is there a medical doctor on your staff? Yes No Do they work out of your office? Yes No
2.2 Give name and degree of your supporting doctor:
2.3 Do you want to cover your medical director on the policy? Yes No
2.4 If yes, indicate any claims they have had in their medical career:
2.5 Is the doctor a medical director for other facilities? Yes No
2.6 If so, should coverage be extended? Yes No
Number of facilities:
For what services:
III. LASER/IPL/RADIO FREQUENCY SERVICES
3.1 Do you have everyone sign a consent form? Yes No We must receive a copy of the form(s) you use.
3.2 Do you use a medical history form on everyone? Yes No
3.3 Do you provide goggles or eye shields for all laser/IPL work on faces? Yes No
3.4 Are you in compliance with all FDA and state laws as to use of lasers/IPLs/Light devices? Yes 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 experiencewith
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 1.5 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
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
I will use PPIB forms: Signed: Title:
I am submitting my own forms for approval: Signed: Title:
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 Photo Rejuvenation Tattoo removal Rosacea Skin Tag Removal
Veins (up to 1.5mm, spider veins) Nonablative wrinkle reduction Cellulite Reduction Toe Fungus Age/sun spots
Smoking Cessation Laser Acupuncture Weight Loss Laser allergy services Laser acupuncture Radio Frequency
4. What other services, not listed above, do you offer?
5. Education in light source equipment: List all information as requested
Date Class Title Number of Hours
Photocopy this page if covering more than 3 people

IV. BOTOX/DERMAL FILLER OPERATOR
4.1 Are you in compliance with all AMA and state laws as to use of Botox & Fillers? Yes No
4.2 Do you have everyone sign a consent & medical history form? Yes 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. I will only buy Botox from an approved Allergan wholesaler, Xeomin from an approved Merz wholesaler or Dysport from
an approved Medicis wholesaler.
3. Botox coverage is only provided for work on patients over 16.
4. Every client must sign a consent form and no coverage will apply if there is not a signed form on file.
5. No coverage is provided for work on pregnant or nursing women.
6. I understand each technician must have training or 6 months experience to be eligible for injectable coverage
We prefer you use PPIBs approved consentforms that are available at www.medispa-ins.com
I will use my own forms: Signed: Title:
V. SUPPLEMENTS/VITAMINS/HORMONES
5.1 Name & Degree of Operator:
Name & Degree of Operator:
Name & Degree of Operator:
5.2 Vitamins & Supplements you are providing
B12 B Complex Chromium Glycine Amino Acids Vitamin C
Other (please describe)
5.3 Hormone services you are providing
Male treatments? Yes No If Yes, what types:
Female treatments? Yes No If Yes, what types:
BioIdentical Hormones Others:
5.4 Do you provide ingestible vitamins/supplements/hormones/herbs? Yes No
If Yes, what types:
5.5 Do you provide injections of vitamins/supplements/hormones? Yes No
5.6 Do you provide consent forms for the above? Yes No We must receive a copy of the form(s) you use.
We prefer you use PPIBs approved consent and medical history forms that are available at www.medispa-ins.com
I will use my own forms : Signed: Title:

VI. LED/MICROCURRENT/ULTRASOUND/
TEETH WHITENING/HAIR STIMULATION
TEETH WHITENING
6.3a Total Number of Units to be covered?
6.3a Have all operators been trained in LED Teeth Whitening? Yes No
6.3a Do you provide customers with home whitening products? Yes No
6.3a If yes, do you provide written instructions for home use? Yes No
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 for coverage to apply only trained technicians will turn on or operate the LED Device.
4. I understand if I treat pregnant women a written doctor’s approval will be on file.
HAIR STIMULATION
6.4a Total Number of Units to be covered?
6.4b Have all operators been trained in LED Hair Stimulation Devices? Yes No
6.4c Do you use Monoxidil in conjunction with the device? Yes No
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 Dated:
LED/MICROCURRENT
6.1a OPERATOR(s) TO BE NAMED:
6.1b Have you been trained in LED & Microcurrent equipment: Yes No
I will have everyone sign a consent form: Signed: Title:
ULTRASOUND
6.2a OPERATOR(s) TO BE NAMED:
6.2b Have you been trained in Ultrasound equipment: Yes No
6.2d What services do you offer with Ultrasound:
I will have everyone sign a consent form: Signed: Title:

VII. LASER/ULTRASOUND ASSISTED LIPOLYSIS/LIPOSUCTION
7.1 OPERATOR TO BE NAMED:
7.2 Licenses you hold & license numbers:
7.3a How long have you been providing Lipolysis services?
7.3b Device being used for Lipolysis
7.4a How long have you been providing Tumescent Liposuction services?
7.4b Do you provide additional liposuction services that are not Tumescent?
7.5 Education in Lipolysis/Liposcution : List all classes and include certificates of completion and your CV
7.6 What other Lipolysis or Liposuction services do you provide? Must list everything for coverage to be considered:
7.7 Do you provide fat transfer injections? Yes No
7.8 Do you have everyone sign a consent form?
Use of these forms is warranted on the policy.
Yes No We must receive a copy of the form(s) you use.
VIII. MESOTHERAPY SERVICES
8.1 Do you have everyone sign a consent & medical history form? Yes No Please provide copies of form
8.2 Do you give everyone aftercare? Yes No
We prefer you use PPIBs approved consent and medical history forms that are available at www.medispa-ins.com
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. All products used must be purchased from licensed compounding pharmacies (Note only ingredients approved by the
company will be covered)

IX. SCLEROTHERAPY
9.1 Do you have everyone sign a consent & medical history form? Yes No
9.2 Do you give everyone aftercare? Yes No
On behalf of all Sclerotherapy operators, I understand:
1. There is no coverage for work on veins over 1.5mm
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
We prefer you use PPIBs approved consent, medical history and aftercare forms that are available at www.medispa-ins.com
Iwill use my own forms: Signed: Title:
X. WEIGHT LOSS & APPETITE SUPPRESSANTS
10.3 Are you in compliance with all FDA and state laws as to weight loss services? Yes No
10.4a Do you have everyone sign a consent form? Yes No We must receive a copy of the form(s) you use.
10.4b Do you have everyone complete a medical history form? Yes No We must receive a copy of the form(s) you use.
PROFESSIONAL INFORMATION
10.5 How long have you been performing weight loss services?
10.6 How many approximate patients have you treated for weight loss?
10.7 What is your gross annual income from weight loss services?
10.8 Education in weight loss: List all classes and include certificates of completion and your CV
10.9a What products do you use for weight loss? HCG Phentermine Lipotropics Phendimetrazine Didrex
10.9b 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

XI. HAIR TRANSPLANT & RESTORATION SERVICES
11.3 Are you in compliance with all FDA and state laws as to hair loss services? Yes No
11.4a Do you have everyone sign a consent form? Yes No We must receive a copy of the form(s) you use.
11.4b Do you have everyone complete a medical history form? Yes No We must receive a copy of the form(s) you use.
PROFESSIONAL INFORMATION
11.5 How long have you been performing hair loss services?
11.6a How many approximate patients have you treated for hair loss?
11.6b What is your gross annual income from hair loss services?
11.7a What systems do you use for hair loss services? NeoGraft FUE Method Strip Method
11.7b What other hair loss services do you provide? Must list everything for coverage to be considered:
11.8 Education in above systems: List all classes and include your CV
11.9 Do you provide hair loss products? Yes No
If Yes, what types:
We prefer you use the carrier approved consent and medical history forms that are available at www.medispa-ins.com

SCHEDULE OF SERVICESDERMAL
FILLERS Technician Degree or License Type Yrs of Experience
1.
2.
3.
4.
5.
Check All To Be Covered: Botox/ Dysport/Xeomin If yes do you perform any of the following?
Hyperhydrosis * Masseters* House Parties*
Injectables/Others:
Restylane Captique Zyplast Sculptra Juvederm Perlane
Radiesse Prevelle Silk Selphyl /PRP* Tear Troughs* Belotero
Injectables on Hands* Latisse
Other: __________________________________________________________
*Additional Premium May Apply
SCLEROTHERAPY
Technician Degree or License Type Yrs of Experience
1.
2.
3.
4.
5.
MESOTHERAPY
Technician Degree or License Type Yrs of Experience
1.
2.
3.
4.
5.
OTHER
SERVICES
Technician Services Provided Yrs of Experience
1.
2.
3.
4.
5.
Do you have insurance for the “Other” services listed above? Yes No
Do you want the License Action Endorsement for an additional
premium of $100?
Yes No
Do you want to include coverage for HIPAA Defense? Yes No

XII - HISTORY: NOTE: All questions must be answered. Failure to disclose claims history could invalidate coverage.
12.1 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:
12.2 Have you ever had professional liability insured refused, declined, cancelled or accepted on special
terms? If yes, provide details on a separate sheet
Yes No
12.3 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
12.4 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
12.5 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
12.6 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
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 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 TITLE
DATE REQUESTED EFFECTIVE DATE LIABILITY LIMIT REQUESTED
Can we email you your policy (usually within 2-3 weeks) Yes 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:

Business Owners Application
1.1 Applicant Name: Phone:
Business Name: Website:
Mailing Address: City: State: Zip:
Business Address:
County: Square Footage of Business
Business operated as: Corporation Parternship Individual Independent Contractor
1.2 Business operated as salon? If not, other:
1.3 How long in business? Do all professionals have licenses?
1.4 Do you have operations not listed on the schedule? If yes, provide details:
Do you have insurance for these operations? Name of insurance company:
PROPERTY SECTION MUST INSURE FOR 100% OF THE REPLACEMENT COST
2.1 Age of building: Construction: Number of stories:
2.2 If building is over 20 years old, when were the following upgraded? (*) Information is Required
*Roof: *Plumbing: *Wiring: Sprinklers:
2.3 *Central Station Burglar Alarm? Yes No If yes advise alarm provider :
2.4 Other Occupancies in building? (Describe)
2.5 Adjoining Occupancies: LEFT: RIGHT:
2.6 Approximate distance from fire station: Distance from fire hydrant:
2.7 Do you sell clothing? Yes No If yes, Inventory Value: $
2.8 Do you sell or use jewelry? Yes No If yes, Jewelry Value: $
2.9 Name & address of loss payee:
COVERAGES DESIRED
CONTENTS – Limit Needed: $ Deductible $1,000
BUILDING – Limit Needed: $ Deductible $1,000
EARNINGS – Limit Needed: $ For What Period? ________________
SIGN – Limit Needed: $ Deductible $100
CLAIMS
3.1 List all property claims in the past 5 years, whether or not insured:
3.2 Current property insurance carrier, policy number:

PART IV. HISTORY
NOTE: All questions must be answered. Failure to disclose claims history could invalidate coverage.
4.1 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:
4.2 List liability claims history arising from any business or other professional activity, whether or not insured:
If none, state so_____________
YR/Claim Nature of injuries Equip. Involved Details, if Pending Amt. if settled
4.3 Do you have knowledge of an event, circumstance or occurrence (other than listed in 4.2 above) 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?
Yes No. If yes, describe details of the event:
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 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.
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 TITLE
DATE REQUESTED EFFECTIVE DATE LIABILITY LIMIT REQUESTED
ADDITIONAL INSURED: @ $50 Certificate Holder (Landlord or Lessor) If necessary, add other names on separate paper.
NAME:
ADDRESS:
Relationship to your business (Landlord, lienholder):

POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM INSURANCE COVERAGE
You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that
you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined
in Section 102(1) of the Act, as amended: The term “act of terrorism” means any act that is certified by
the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the
United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life,
property, or infrastructure; to have resulted in damage within the United States, or outside the United States
in the case of an air carrier or vessel or the premises of a United States mission; and to have been
committed by an individual or individuals, as part of an effort to coerce the civilian population of the
United States or to influence the policy or affect the conduct of the United States Government by coercion.
Any coverage you purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2014, the
date on which the TRIA Program is scheduled to terminate or the expiry date of the policy whichever
occurs first, and shall not cover any losses or events which arise after the earlier of these dates.
YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED
BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES
UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAY
CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE, SUCH AS AN
EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS
85% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED
DEDUCTIBLE PAID BY THE INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO
KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100
BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS'
LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE
AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE
AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR
COVERAGE MAY BE REDUCED.
THE PREMIUM CHARGED FOR THIS COVERAGE WILL BE PROVIDED IF ACCEPTED, PRIOR
TO BINDING. IT WILL NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED
BY THE FEDERAL GOVERNMENT UNDER THE ACT.
I hereby elect to purchase coverage for acts of terrorism for a prospective
premium of ______________________
I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand
that I will have no coverage for losses arising from acts of terrorism.
_____________________________ Underwriter’s at Lloyd’s, London
Policyholder/Applicant’s Signature Insurance Company
Print Name Policy Number
_____________________________
Date

PL & GL for Medi Spas, Beauty Salons, Gyms

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