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Medical Spa Professional Liability Application

NOTICE

This is an application for a claims-made and reported policy, which subject to its provisions applies only to claims which are both first made against the insured and reported to the insurer during the policy period or any extended reporting period, if applicable. Claim expenses are included within the limit of liability. The information contained and statements made within this application are incorporated into, and will form the basis of, any policy of insurance issued by the insurer. The applicant and all signors of this application warrant that the information conveyed is true and correct. The limit of liability available to pay settlements or judgments will be reduced, and may be exhausted, by claim expenses.

"*" indicates required fields

Please fully answer all questions and submit requested information. Boldfaced terms are defined in the Policy and have the same meaning in this Application. Any information provided, whether physically attached or available on the Applicant’s web site, shall be deemed incorporated into this Application.

SECTION I – GENERAL INFORMATION

Mailing & Location Address (If multiple locations, include an atachment with a complete list of locations)

Locations:

Are all of the applicant’s locations equipped with:

a. Smoke detectors
b. Fire extinguishers

Does the applicant have any:

a. Exposure to flammables, explosives, chemicals?
b. Firearms on the premises?
c. Animals on the premises?
d. Swimming pool?
e. Steam rooms or saunas?

If “yes” to any of the above, please provide additional details in the Additional Comments section below.

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Type of Entity:

Is this entity owned by, associated with, or controlled by any other entity?
Does the applicant own, operate, or manage any business other than the one(s) described in this application for which you are applying for coverage?

Within the next 12-month period, does the applicant plan to:

a. Obtain another operation or entity?
b. Add to the number of employees?
c. Expand the number of locations?
d. Eliminate current services or add new services?
e. Operate in other states?

SECTION II – STAFF

Provide the number of the employees or independent contractors and whether or not they carry their own individual medical malpractice coverage* for their services on behalf of this entity:

Physicians (no surgery)

Insured on Own Med Mal Policy

Physicians (surgical)

Insured on Own Med Mal Policy

Physician Assistants

Insured on Own Med Mal Policy

Nurse Practitioners / APRNs

Insured on Own Med Mal Policy

CRNAs

Insured on Own Med Mal Policy

Surgical Technicians

Insured on Own Med Mal Policy

Nurses (RN/LPN/LVN)

Insured on Own Med Mal Policy

Aestheticians

Insured on Own Med Mal Policy

Laser Techs

Insured on Own Med Mal Policy

Medical Assistants

Insured on Own Med Mal Policy

Massage Therapists

Insured on Own Med Mal Policy

Cosmetologists

Insured on Own Med Mal Policy
Insured on Own Med Mal Policy

* Atach copies of declaration pages on all individuals that carry their own malpractice.

Do you provide any services rendered within a correctional facility or center, detention center, jail, penal institution, prison, remand center, reformatory, or any similar center, facility, or institution?
Do you require all of your independent contractors to carry Professional Liability?
Are all of the above individuals licensed in accordance with all applicable state and federal regulations?
Do you have a Medical Director?
b) Would you like to include coverage for the Medical Director’s supervisoryduties over PA-c, NP, or APRNs at this facility?
c) Would you like to include coverage for the Medical Director’s direct patient care?

Has the applicant or any of the above employees and/or independent contractors:

Ever been the subject of disciplinary or investigative proceedings or been reprimanded by a governmental or administrative agency, hospital, or professional association?
Ever been convicted of a criminal act other than traffic offenses?
Ever been treated for alcoholism or drug addiction?
Ever had any state professional license or license to prescribe narcotics suspended, revoked, renewal refused or restricted, or ever voluntarily surrendered same? If Yes to any of the above questions,

SECTION III – FACILITY OPERATIONS

State sources and amounts of total revenue:

Fee for Service

Product Sales

Medical Equipment Rental

Other Income

Total Gross Revenue

Indicate the estimated number of procedures to be performed over the next 12 months in all of the following categories: NON-INVASIVE, NON-INJECTABLE, NON-ABRASIVE SKIN CARE & DAY SPA TYPE PROCEDURES

NON-INVASIVE, NON-INJECTABLE, NON-ABRASIVE SKIN CARE & DAY SPA TYPE PROCEDURES :

#Body & Facial Waxing

#Hair, Manicures, Pedicures

#Facials

#Massage

NON-INVASIVE PROCEDURES, INJECTABLES, ABRASIVE SKIN CARE & NON-LASER REMOVAL PROCEDURES

NON-INVASIVE PROCEDURES, INJECTABLES, ABRASIVE SKIN CARE & NON-LASER REMOVAL PROCEDURES :

#Body & Facial Waxing

#BHRT (no pellet insertion)

#Brown Spot Removal – Non

#Chemical Peels (Light)

#Botox / Dermal Fillers Other

#Dermaplaning

#Electrolysis

#Mesotherapy / Injection

#HCG

#Microdermabrasion

#Microneedling

#Permanent Make Up

#Platelet Rich Plasma Therapy

#Plasma Pen

#P-shots / O-shots

#Skin Tag / Wart Removal

#Testosterone Injections

#Other

NON-INVASIVE PROCEDURES, INJECTABLES, ABRASIVE SKIN CARE & NON-LASER REMOVAL PROCEDURES

NON-INVASIVE PROCEDURES, INJECTABLES, ABRASIVE SKIN CARE & NON-LASER REMOVAL PROCEDURES :

#BHRT (pellet insertion)

#Brown Spot Removal

#Laser Skin Tightening

#Heavy Chemical Peels

#IPL

#Laser Lipolysis (Non-surgical)

#Laser Hair Removal

#Laser Skin Resurfacing

#Pigmented Lesion Removal

#RF Skin Tightening

#Sclerotherapy / Vein Treatments

#Tattoo Removal (Laser Based Treatment)

#Vaginal Rejuvenation

#Velashape

MINOR FACIAL COSMETIC SURGERY,
NON-LIPOSUCTION BASED COSMETIC SURGERY

MINOR FACIAL COSMETIC SURGERY, NON-LIPOSUCTION BASED COSMETIC SURGERY :

#Blepharoplasty

#Ear Pinning

#Hair Restoration/Hair Transplant Surgery

#PDO Threadlifts

#Threadlifts – all other

#Other :

COSMETIC SURGERY PROCEDURES
AND INVASIVE LIPO PROCEDURES

COSMETIC SURGERY PROCEDURES AND INVASIVE LIPO PROCEDURES :

#Abdominoplasty or Tummy Tucks

#Brazilian Butt Lift or Buttocks Augmentation

#Hair Restoration/Hair Transplant Surgery

#Face Lifts – Full Face Laser Lipolysis

#Liposelection

#Liposuction – Tumescent or Other

#Surgical Laser Lipolysis (Smart Lipo)

#Fat Grafts / Transfers other than buttocks

REGENERATIVE MEDICINE

REGENERATIVE MEDICINE :

#Exosomes treatments

#Stem Cell – Injections

#Lipodissolve Stem Cell Therapy

#Stem Cell treatments

#Stem Cell – IV

#Other

NON-INVASIVE WEIGHT LOSS TREATMENT

NON-INVASIVE WEIGHT LOSS TREATMENT :

#Non-Invasive Weight Loss Treatment

#Non-Invasive Weight Loss Treatment

ALL OTHER NON-SURGICAL PROCEDURES

ALL OTHER NON-SURGICAL PROCEDURES :

#Wellness visits (NOC)

#Chiro / Osteo Manipulations

#Compression therapy

#Cryotherapy (Whole Body)

#Cryo – local treatment

#Hypnotherapy

#IV hydration / therapy

#Ketamine treatments

#Non-Invasive Weight Loss Treatment

#Medical Marijuana Medical Card Evals

#Chiro / Osteo Manipulations

#Chelation

#HBOT – elective

#HBOT – wound care

#Red Light therapy

#Ozone Therapy

#Vitamin Injections

#Non-Invasive Weight Loss Treatment

Do you perform any surgery at this facility not detailed above?

If Yes, provide a list of these surgical procedures and the estimated number of surgeries for the next 12 months.

What type of anesthesia care is used at the medical spa who is it administered by?

Local Anesthesia Only
Conscious Sedation
General Anesthesia
Other
Does your practice include prescribing of opioids?

If Yes, provide the following details:

a. Do you fully comply with the CDC Guideline for Prescribing Opioids?
b. Does your practice adhere to any and all prescription drug monitoring program (PDMP) requirements in the state(s) where you conduct business?
Do you also dispense the opioids?
Does your practice include Pain Management?
Are FDA Approved Drugs ever used for “off-label” purposes?
Do you ever provide any services at locations other than your medical spa?

If Yes, provide the following details:

Will alcohol be served to these off-site patients?

If the applicant has a training school, please provide the following

Is the school accredited by an outside accrediting entity?
Does completion of the courses provided result in licensing?

SECTION IV – NETWORK SECURITY AND DATA PRIVACY PROCEDURES

Do you currently purchase a standalone cyber policy?

If Yes, please provide the following information:

Do you employ the following tools to protect private sensitive data?

a) Anti-Virus and Firewalls
b) Encryption
c) Formal Password Management Procedures
Are you compliant with the Health Information Portability and Accountability Act (HIPAA) and Health Information Technology for Economic Critical Health Act (HITECH)?
Have you ever experienced a security breach, data loss, or denial of service atack? If Yes, please complete a Supplemental Claim Information Form for each and every claim.

SECTION V – COVERAGE HISTORY

Provide the following information as respects the last five years of professional liability coverage beginning with the most current coverage: (If none, state NONE.)

Are you currently insured under a General Liability policy?
Are you interested in a quote for General Liability?

SECTION VI – RISK MANAGEMENT AND CLAIMS HISTORY

Do you have a Quality Assurance and Risk Management Program in place?

Before and after photos

For which procedures are before and after pictures are taken?

Procedure consent forms

Are clients required to sign a form specific to the procedure to be performed prior to treatment?
Are staff also required to sign a form specific to the procedure when receiving services?
Does the applicant provide writen post-operative instructions for all procedures performed?
Are signed consent forms maintained in the client’s file?
Has any application for professional liability insurance made on behalf of the applicant, any predecessors in business, or present partners ever been declined, canceled or non-renewed?
Has any claim ever been made against the applicant or any of its employees? If Yes, complete the Supplemental Claim Information Form for each and every claim.
Does the applicant currently have any open claims?
Is the applicant aware of any errors, omissions, circumstances, or incidents which may result in a claim being made against them or their employees, or are there any claims that have not yet been reported?

SECTION VII – COMMENTS

Fraud Prevention – General Warning

NOTICE: Any person who knowingly, or knowingly assist another, files an application for insurance or claim containing any false, incomplete or misleading information for the purpose of defrauding or attempting to defraud an Insurance Company may be guilty of a crime and may be subject to criminal and civil penalties and loss of insurance benefits

Attention: Insureds in AL
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.
Attention: Insureds in CO
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Attention: Insureds in DC
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Attention: Insureds in FL
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Attention: Insureds in KS
A person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with the intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.
Attention: Insureds in KY
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Attention: Insureds in LA
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Attention: Insureds in MD
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Attention: Insureds in ME
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Attention: Insureds in MN
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Attention: Insureds in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Attention: Insureds in NM
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
Attention: Insureds in OH
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Attention: Insureds in OK
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Attention: Insureds in OR
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that:

A. The misinformation is material to the content of the policy;
B. We relied upon the misinformation; and
C. The information was either:
1)Material to the risk assumed by us; or
2)Provided fraudulently.
For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests. With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud.
Attention: Insureds in PA
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Attention: Insureds in RI
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Attention: Insureds in TN, VA, and WA
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Attention: Insureds in VT
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Notice to all other state Applicants:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.


THE UNDERSIGNED AUTHORIZED EMPLOYEE OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED EMPLOYEE AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE UNDERWRITER OF SUCH CHANGES, AND THE UNDERWRITER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. FOR NEW HAMPSHIRE APPLICANTS, THE FOREGOING STATEMENT IS LIMITED TO THE BEST OF THE UNDERSIGNED’S KNOWLEDGE, AFTER REASONABLE INQUIRY. IN MAINE, THE UNDERWRITERS MAY MODIFY BUT MAY NOT WITHDRAW ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE

NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALL CONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDER ANY CONTRACT OF INSURANCE.

SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BECOME PART OF THE POLICY.

ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. FOR NORTH CAROLINA, UTAH, AND WISCONSIN APPLICANTS, SUCH APPLICATION MATERIALS ARE PART OF THE POLICY, IF ISSUED, ONLY IF ATTACHED AT ISSUANCE

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