Pricing Beauty Services

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Pricing Beauty Services

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Please email us at: service@cisrocks.com once completed to be sure that we have received your form correctly. We look forward to assisting you!

* Indicates required field

When do you need this insurance coverage by? *

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

Applicant Name *

First

Last

Your Business Name (if none, type none) *

Phone Number *

D.O.B. *

Date of Birth

Email *

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

Line 1 *

Line 2 *

City *

State *

Zip Code *

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: *

Corporation LLC LLP Partnership Individual Sole Proprietorship Independent Contractor

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 *

Max file size: 20MB

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 all professionals have licenses? *

Aesthetician Cosmetologist Tattoo Artist MD, RN, NP None

Do you offer any treatments that include topical CBD/Hemp products? *

Yes No

Do you private label products for sale? *

Yes No

Do you sell any CBD/Hemp Products? *

Yes No

Gross receipts *

Products Liability needed for take home products sold by you *

Yes No

Gross receipts *

Do you sell non - beauty related products? *

Yes No

If yes, describe products *

Please select all services you would like a quote for:

Please select the services you provide below: *

Manicurist Beautician / Barber Massage Therapist Hyaluron Services Fibroblast Plasma Services Topical PRP Personal Trainer Acupuncture Pilates / Yoga Hypnosis BB Glow Removal of Moles Colon Hydrotherapy Injectables Cryotherapy Cryo Skin Wellness Nano-needling LED Teeth Whitening Foot Detox UV Tanning Blood Draws PRP PDO Threading

Body Contouring / Cellulite Reduction: *

Yes No

If, Yes Name of Device: *

Permanent Makeup: *

Eyeliner Eyebrows Microblading Lips Lip liner Nipple areola Scar Camouflage Cheek Blush Repigmentation Microshading Ombre Brows

Pigment Removal: *

Yes No

If Yes, Specify Products: *

Permanent Makeup Years of Experience: *

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

Please upload any credentials you like the underwriter to see *

Max file size: 20MB

File #2 *

Max file size: 20MB

File #3 *

Max file size: 20MB

File #4 *

Max file size: 20MB

File # 5 *

Max file size: 20MB

Topical makeup Eyelash & Eyebrow Extensions/Tinting Threading Waxing Sugaring (hair & nails)

Spray tanning Aesthetic facials Aesthetic peels Electrology Microdermabrasion Needling/collagen induction therapy under 1.0 deep Piercings Ear candling Aesthetic radio frequency Manicures Pedicures

Medical grade peels Needling/collagen induction therapy Cosmetic ultrasound LED/microcurrent Dermaplaning Skin tag removal Wart removal Aesthetic cryo-spot treatments

Intense Pulse Light Laser Cold or High Heat Radio Frequency Ultrasound High Frequency

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? *

Additional Comments: *

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Califonia Lic # 0801925 | NPN # 2543434

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Champ Insurance Services
California license # 0801925
National Producer # 2543434
92 Corporate Park C 777
Irvine CA, 92606
(949) 535-1099
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