Med Spa Insurance Quote

Med Spa Insurance Quote Request Form

Please complete this form to request a commercial insurance quote for your med spa. Accurate and complete information helps us provide the best insurance options for your business.

Business Information

Legal Business Name *

DBA (Doing Business As)

Business Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Mailing Address (if different)

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number *

Email Address *

Website or Social Media Page

Business Entity Type *

LLCCorporationPartnershipSole Proprietor

Year Business Started *

Years of Experience in the Industry *

EIN Number *

Owner Information

Please provide the owner's contact and ownership information.

Owner Full Name *

Owner Phone Number *

Owner Email Address *

Ownership Percentage *

Medical Oversight

Please provide information about your Med Spa's medical oversight.

Is there a Medical Director? *

YesNo

Medical Director Name

Medical Director License Type

MDDONurse PractitionerPhysician Assistant

Is the Medical Director On-Site?

Full TimePart TimeOn Call Only

Staff Information

Please provide details about your Med Spa staff.

Total Number of Employees *

Physicians

Nurse Practitioners

Physician Assistants

Registered Nurses

Licensed Estheticians

Laser Technicians

Administrative Staff

Are all medical professionals licensed? *

YesNo

Equipment Used

Please select the equipment used by your Med Spa.

Does the Med Spa use any of the following equipment?

Laser DevicesRadiofrequency DevicesCryotherapy EquipmentIV Infusion EquipmentBody Sculpting MachinesCoolSculptingOther Medical EquipmentOther — Please type another option here

Please list the brand and model of major equipment (e.g., Candela Laser, CoolSculpting Machine, HydraFacial Device)

Business Location

Please provide information about your business location.

Square Footage of Business Location *

Do you: *

Own the buildingLease the spaceOperate inside another business

Insurance History

Please provide information about your current insurance coverage.

Do you currently have insurance? *

YesNo

Current Insurance Carrier

Policy Expiration Date

Claims History

Please provide information about any claims or incidents.

Any claims or incidents in the past 5 years? *

YesNo

If yes, please explain

Coverage Requested

Please select the coverages you are looking for.

What coverages are you looking for?

General LiabilityProfessional Liability (Malpractice)Business Personal PropertyEquipment CoverageCyber LiabilityWorkers Compensation

Upload Supporting Documents

Please upload any supporting documents available for your insurance quote.

Upload Current Insurance Declarations Page (DEC Page)

Upload Loss Runs (Last 3–5 Years)

Upload Professional Licenses

Upload Photos of Business Location (Optional)

Additional Information

Please provide any additional information about your Med Spa operations.

Please provide any additional details about your operations

Authorization

I certify that the information provided is accurate to the best of my knowledge.

Signature *

Date *

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Your information is secure.

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