Day Spa Insurance | Champ Insurance Agency Inc.

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Day Spa - MediSpa - Beauty Services Quote

When do you need this insurance coverage by?

What is the best form of contact for us to reach you?

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Applicant Name

First

Last

Your Business Name (if none, type none)

Phone Number

D.O.B.

Email

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Your Physical Mailing Address (No P.O. Box)

Line 1

Line 2

City

State

Zip Code

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Business Address

Line 1

Line 2

City

State

Zip Code

Square Footage / Sqft

Annual gross receipts from all operations?

How long have you been in business?

Business Operated as:

Are you in compliance with all FDA, AMA guidelines as well as City, County, and State Ordinances?

Yes

No

Do you need General Liability?

Yes

No

If no, what Company Insures your General Liability Coverage?

Are you required to name any other person or entity as an Additional Insured on your Policy?

Yes

No

Please Provide Landlord, Lease, Rental, or Equipment Agreement

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Do you currently have Professional Liability Insurance Coverage?

Yes

No

If yes, Name of Insurance Company providing the coverage.

Do you have a Medical Director on staff:

Yes

No

If yes: Name of Medical Director & Medical Designation

Do you provide services of your home?

Yes

No

Do you provide services in homes of clients?

Yes

No

Do you intend to cover artist working under your business name?

Yes

No

In 1099 artists who will carry their own insurance with my business listed as additional insured.

Yes

No

Do you have any employee on payroll?

Yes

No

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Please select all services you would like a quote for:

Body Contouring / Cellulite Reduction:

Yes

No

If, Yes Name of Device:

Pigment Removal:

Yes

No

If Yes, Specify Products:

Permanent Makeup Years of Experience:

Will you be teaching any beauty services listed?

Yes

No

If so, which services would you like to teach?

Years of experience in area being taught?

Total Number of Procedures Performed:

Total Hours of Instruction:

Are all students being taught 18 years of age or older?

Yes

No

How Many Students will be trained in the next 12 months?

Maximum number of students per class?

How many hands on procedures will each student perform?

How did you hear about us?

Please tell us if there are any other services not listed above that you are wanting coverage for:

Additional Comments:

Please upload any credentials you like the underwriter to see

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Day Spa - MediSpa - Beauty Services Quote

Day Spa - MediSpa - Beauty Services Quote

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