Fillable AH CLINIC MEDICAL SPA COMBO 1 (Kinsale Insurance)

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AH CLINIC MEDICAL SPA COMBO 1 (Kinsale Insurance)

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Page 1 of 14
Requesting Professional Liability:
Requested Retro Date: _________
Professional Liability Limits
Professional Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Other: _______________
Requesting General Liability:
Requested Retro Date: _________ or Occurrence Based Coverage
General Liability Limits
General Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Other: _______________
Requesting Employee Benefits Liability (supplement required):
Requested Retro Date: _________
Employee Benefits Liability Limits
Employee Benefits Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$1,000
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Requesting Non-Owned Auto Liability (supplement required):
Non-Owned Auto Liability Limits
$100,000
$200,000
$250,000
$500,000
$1,000,000
Other: _______________
*Requested coverage may or may not be offered please review any quote issued for actual terms
and conditions available. Completion of this application neither binds coverage nor guarantees
that policy will be issued.
REQUESTED COVERAGE – OUTPATIENT CLINIC / MEDICAL SPA COMBO
Page 2 of 14
APPLICATION FOR CLINICS (Medical, Dental, Public Health)
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra sheets as
necessary should you run out of space provided. An incomplete or illegible application cannot be processed. Completion of this
application neither binds coverage nor guarantees that a policy will be issued.
• Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days before the
proposed effective date of coverage.
• If a question is not applicable, then state “N/A”.
• The following information must be submitted with the completed application:
- Copy of your current professional liability insurance Declarations Page (claims made policies must reflect the
retroactive date)
- Copy of all advertising that you use
- 5-year company loss runs, valued within the last 60 days
GENERAL INFORMATION
1. Full name of Applicant (Including DBA’s) ___________________________________________________________________
8. Date Established _____________________ Years under current management _____________
9. Applicant is a:
Individual
Professional Associations
Corporation
Partnership
LLC
Joint Venture
Other:____________________________________
10. Enterprise is: For Profit Not For Profit
2. Mailing Address:______________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
3. Location Address: Check here if same as mailing:
(1) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(4) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Attach Additional Pages as Needed
4. Website Address: www._______________________________
5. Telephone: ______________________
6. Inspection/Risk Management Contact Name:
7. Inspection/Risk Management Contact E-mail:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 3 of 14
11. Is this entity owned by, associated with or controlled by any other entity? Yes No
If yes, please provide details:
___________________________________________________________________________________________
___________________________________________________________________________________________
OPERATIONS
12. Please check the category which best describes your organization
Health and Wellness Center
Center or clinics established for primarily walk-in patients for basic health and
health-related services. Primary care providers predominantly RNs or LPNs, NPs,
and physician assistants. Facilities in this category would include free clinics open
to the public or those provided for students/faculty of schools, colleges,
universities.
Primary Care Clinic
Majority of patient visits are scheduled preventative health services. This
category can also include extended hours walk-in clinics where u
rgent care
services are not the primary services provided by your organization. Your regular
office hours have been extended to include the addition of walk-in care services.
Primary care givers during these hours could include physicians or mid-level
providers, although physicians are available during the extended hours.
Urgent Care Center
Urgent care services are the primary activities performed by your organization.
Physicians regularly staff your locations with the support of mid-level providers.
Services provided are sometimes broader in scope than those typically found in a
physician’s office. Locations may offer a range of services including physical
therapy, occupational therapy, occupational health (Workers Compensation
exams), on site x-ray and clinical lab.
Emergi-Center
High level of acuity and may include minor invasive procedures such as those
provided in emergency care centers/emergency rooms.
Services would also
include high level treatment for trauma or severe illness and crisis stabilization.
Treatments may require moderate to high levels of anesthesia
Other
Please provide a description of your organization if it does not readily reflect one
of the above categories.
__________________________________________________________________
__________________________________________________________________
13. Please list all accreditations and association memberships held by the applicant’s facility (Joint Commission, AAAHC, etc):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
14. Days and Hours of Operation: ________________________________________
15. Please state sources and amounts of total revenue:
Source Last 12 months Next 12 months
Charitable contributions $________________ $_________________
Government Funding $________________ $_________________
Fee for services $________________ $_________________
Other – specify: $________________ $_________________
TOTAL GROSS REVENUES $________________ $_________________
Page 4 of 14
16. Please indicate number of patient visits:
Past 12 Months Estimated Next 12 Months
Emergency Visits _______________ _______________
Urgent Care visits _______________ _______________
Health/ Wellness Visits _______________ _______________
Other:___________________ _______________ _______________
TOTAL VISTS _______________ _______________
17. If your facility offers any of the following services on site please provide the number of tests, prescriptions, or imaging
studies respectively performed:
Past 12 Months Estimated next 12 Months
X-ray / Imaging _______________ ___________________
Pharmacy _______________ ___________________
Laboratory _______________ ___________________
Are any of these services offered to individuals who are not your facility’s primary patient? YES NO N/A
18. Please indicate percentage of patients among the following:
_____ % Urgent Care _____% Alternative Medicine
_____% Emergency Care _____% Women’s Health/ Gynecological
_____% General Practice / Family Practice _____% Sleep Studies
_____% Dialysis _____% Psychiatric
_____% Occupational health _____% Weight loss
_____% Students _____% Crisis Stabilization
_____% Surgical
_____% Other (please describe) ______________________________________
19. Does the applicant maintain any beds for overnight occupancy?
If yes, please provide total number ________
YES NO
20. Is anesthesia administered by the applicant, the applicant’s employees or independent contractors other
than topical or local? If yes please provide a detail explanation on page 6
YES NO
21. Does the applicant’s employees or independent contractors perform any prenatal care or obstetrical
procedures? If yes, please provide details on page 6
YES NO
22. Does the applicant, employees, or independent contractors use drugs for weight reduction?
If yes, attach list of drugs used and percentage of practice devoted to weight reduction; frequency and
duration of prescriptions or weight reduction drugs and quantity dispensed.
YES NO
23. Does the applicant perform laser hair removal, botox injections or dermal filler injections?
If yes, please
complete medical spa supplement.
YES NO
24. Does the applicant perform any psychiatric shock therapy?
YES NO
25. Does the applicant perform any chelation therapy services?
YES NO
26. Does the applicant administer any methadone treatment?
If yes, provide the number of treatments:
Last 12 Months ___________ Next 12 Months ___________
YES NO
27. Does the applicant maintain written documentation of procedures for patient intake and follow-up?
YES NO
28. Please provide name and location of any hospital or medical facility that the applicant refers in practice?
_____________________________________________________________________________________
Page 5 of 14
STAFF
29. Please indicate the number of employed and contracted staff:
Number Employed?
Number Contracted
Insured
Elsewhere?
Coverage
Desired?
Full Time
Part Time
Full Time
Part Time
Acupuncturists
YES NO
YES NO
Chiropractors*
YES NO
YES NO
Dentists*
YES NO
YES NO
Inhalation/ Respiratory Therapists
YES NO
YES NO
Laboratory Technicians
YES NO
YES NO
Licensed Practical Nurses
YES NO
YES NO
Nurse Anesthetists
YES NO
YES NO
Nurse Midwives*
YES NO
YES NO
Nurse Practitioner
YES NO
YES NO
Opticians
YES NO
YES NO
Optometrists
YES NO
YES NO
Paramedics/ EMT’s
YES NO
YES NO
Perfusionists
YES NO
YES NO
Pharmacists
YES NO
YES NO
Physician Assistant
YES NO
YES NO
Physicians – Major Surgery*
YES NO
YES NO
Physicians – Minor surgery*
YES NO
YES NO
Physicians – No surgery*
YES NO
YES NO
Physicians – OBGYN*
YES NO
YES NO
Physiotherapists
YES NO
YES NO
Registered Nurses
YES NO
YES NO
Social Workers
YES NO
YES NO
Speech Therapists
YES NO
YES NO
X-ray Technicians
YES NO
YES NO
Other: Specify
YES NO
YES NO
* Additional applications required if coverage is desired
30. Please provide the name and specialty of the applicant’s Medical Director: ________________________________________
Does the applicant’s Medical Director have direct patient care? YES NO
Full Time or Part Time
31. Are all above individuals licensed in accordance with applicable state and federal regulations?
YES NO
32. Do you require contracted staff to carry their own professional liability insurance?
If yes, what limits do they carry? ___________________
YES NO
33. Do all physicians (employed and contracted) carry their own professional liability coverage?
If yes, what limits do they carry? ___________________
YES NO
34. Please indicate all of the hiring/screening procedures used for professionals and paraprofessionals who provide patient care
services at your facility:
Check of educational background, or residency program, when applicable.
Check of previous employers ( In writing By Telephone)
Criminal background check ( STATE FEDERAL)
Drug / Alcohol / Abuse Screening (circle all that are used)
Verify any pending license suspensions or revocations, or any pending disciplinary actions by other facilities.
Require information on any professional liability or work-related claim that has previously been made against any
Individual?
35. Does your facility have written job descriptions?
YES NO
Page 6 of 14
COVERAGE HISTORY AND LOSS HISTORY
36. Please list professional liability insurance carried for each of the past five years.
Insurer
Dates covered
Limits of Liability
Per claim/ Aggregate
Deductible
Premium
Retroactive
date
37. If the applicant is currently insured under a commercial general liability policy please list coverage for the past five years.
Insurer
Dates covered
Limits of Liability
Per claim/ Aggregate
Deductible
Premium
Occurrence or
Claims Made
If the current expiring GL policy is claims- made what is the retroactive date? _____________
Provide details for all “yes” answers to questions 37-42 on page 6 or attach additional pages as needed
38. Has the applicant or any of its employees ever had any professional license or license to prescribe and
or dispense narcotics ever been limited, suspended, revoked, denied, or investigated by any licensing
board or regulatory agency? Explain on page 7 or attach additional pages as needed
YES NO
39. Has the applicant or any of its employees ever been charged with, or convicted of a crime other than
minor traffic violations? Explain on page 7 or attach additional pages as needed
YES NO
40. Has the applicant or any of its employees ever been diagnosed or treated for alcoholism, drug
addiction, any chemical dependency, or mental or chronic physical illness? Explain on page 7 or
attach additional pages as needed
YES NO
41. Has any claim or suit for malpractice or professional liability ever been made against the applicant OR
any other person proposed for this insurance? How Many? ______ (Complete Supplemental Claims
form for Each)
YES NO
42. Is the Applicant or any person proposed for this insurance aware of any act, error, omission, fact,
circumstance, or records request from any attorney which may result in a malpractice claim or suit?
If yes, please explain in detail, completing a supplemental claim form for each.
YES NO
43. Has any claim or suit for malpractice ever been made against the Applicant or any person proposed for
this insurance that has not been reported to the Applicant’s current or prior insurer? If yes, please
explain in detail, completing a supplemental claim form for each.
YES NO
Page 7 of 14
GENERAL LIABILITY - complete only if you are requesting GL coverage
44. Building Description
Buildings/Wings
#1 #2 #3 #4
Type of Construction: __________ __________ __________ __________
No. of Stories: __________ __________ __________ __________
Square Footage __________ __________ __________ __________
Date Built: __________ __________ __________ __________
Smoke detectors: Yes No Yes No Yes No Yes No
Local/Central station fire alarm: Yes No Yes No Yes No Yes No
Sprinkler System: Yes No Partial Yes No Partial Yes No Partial Yes No Partial
SUPPLEMENTAL INFORMATION Use the remainder of this page as needed or to address questions referenced within the application
45. Do any of the Applicant’s locations have any (explain any “yes” answers on page 6):
a. Exposure to flammables, explosive, chemicals?
b. Catastrophe exposure?
c. Exposure to radioactive materials?
YES NO
YES NO
YES NO
46. Has any claim for General Liability ever been made against any person(s) or entity(ies) proposed for
this insurance? If Yes, complete a supplemental claims form for each.
YES NO
47. Is (are) any person(s) or entity(ies) proposed for this insurance aware of any fact, circumstance or
situation which may result in a General Liability claim, such that would fall under the proposed
insurance? If Yes, answer complete supplemental claims form for each.
YES NO
Page 8 of 14
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA 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.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
Page 9 of 14
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and
made a part of this application.
Applicant:
_____________________________________
Title:
________________________________
FEIN #:
_____________________________________
Applicant’s Signature:
___________________________
Date:
________________________________
Agent / Broker Name:
______________________________________________________________________
click to sign
signature
click to edit
Page 10 of 14
If reporting more than one claim or incident, please photocopy and complete a separate form for each. Attach additional
sheets if necessary for adequate explanation. All questions must be answered or marked Not Applicable (N/A), and each
sheet must be signed.
Name of Patient:____________________________________________ Age:______ Sex:_______
Incident Claim
Date reported to insurance company: ______________
Name of insurance company: _______________________________________________
Date of incident and your treatment: __________________________________________________________
Allegations / Circumstances: ___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Additional Defendents: _______________________________________________________________________
What is the present condition of the patient?______________________________________________________
___________________________________________________________________________________________
STATUS OF CLAIM
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Reserve amount:
$__________________
Suit settled out of court Court outcome in favor of plaintiff:
a. Date claim paid: _____________ Jury verdict
b. Amount paid: $_____________ Directed verdict
c. Did you want to settle? Amount of loss payment:
Yes No $_____________________
Name and address of the attorney assigned to your case: ____________________________________________
___________________________________________________________________________________________
To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)?
Yes: No:
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________ Date:
Printed Name: __________________________________
SUPPLEMENTAL CLAIM / INCIDENT INFORMATION
Page 11 of 14
MEDICAL SPA SUPPLEMENT
Clinic Application MUST also be completed
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra sheets as
necessary should you run out of space provided. An incomplete or illegible application cannot be processed. Completion of this
application neither binds coverage nor guarantees that a policy will be issued.
GENERAL INFORMATION AND OPERATIONS
1. Full name of Applicant (Including DBA’s) _________________________________________________________________
2. Applicant’s practice is run by:
Nurse
Nurse Practitioner Physician Assistant Dentist Other Individual: ________________________
Physician (specify type)
Dermatologist
Plastic Surgeon
Other ________________________
3. Percentage of clients or patients within the following categories?
Beauty Shop (nails, hair, facial)
_____%
Weight Control
_____%
Massage
_____%
Dental
(to include teeth whitening)
_____%
Hormone Therapy
_____%
Surgical /Plastic Surgery
_____%
Dermatology
(to include acne treatment)
_____%
Medical Spa
_____%
Fitness Club / Yoga or Exercise Classes
_____%
4. Age Range of Clients: _____% Under 18 _____% 18-39 _____% 40-65 _____% Over 65
5. Do you require ALL patients to sign an Informed Consent form prior to any procedure being
performed? If Yes, please attach copies of patient informed consents. If No, please explain.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Yes No
6. If any clients are under the age of 18 – do you require parent/guardian signatures on Informed
Consents? Please indicate all procedures performed on clients under the age of 18 if applicable:
_______________________________________________________________________________
_______________________________________________________________________________
Yes No N/A
7. Do you sell any products with the facility’s name and/or label on them? If yes, attach complete
product list and indicate corresponding annual sales.
Yes No
8. Do you sell any dietary supplements or prescribe any weight loss medication? If yes, identify
brand names:
_______________________________________________________________________________
_______________________________________________________________________________
Yes No
9. Do you ever hold off-site events? If yes, please describe:
_______________________________________________________________________________
_______________________________________________________________________________
Yes No
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 12 of 14
10. Are any daycare or childcare services offered to your clients?
Yes No
11. Are any alcoholic beverages sold and or served on premises? Please elaborate if yes:
_______________________________________________________________________________
_______________________________________________________________________________
Yes No
12. Please indicate if any of the following are on your premises – indicate here if “none”
Swimming Pool
Sauna
Steam Room
Whirlpool Type Spa/Tub
Tanning Booths (Number? _____)
13. SERVICES:
PROCEDURES PERFORMED AND PERFORMED BY:
(Check All that Apply also indicating any additional staff that may be performing the procedure)
Yes?
Procedures:
# Annually
LPN
RN
NP
PA
DDS/ DMD
MD / DO
OTHER (must specify name and designation)
ACUPUNCTURE
BOTOX
CHEMICAL PEELS UNDER
30% ACIDITY
CHEMICAL PEELS OVER 30%
ACIDITY
DERMAL FILLERS
FACIALS
HAIR TRANSPLANT
HORMONE THERAPY MEN
HORMONE THERAPY
WOMEN
INTENSE PULSE LIGHT
LASER HAIR REMOVAL
LASER SKIN RESURFACING
LASER VEIN
LASER TATTOO REMOVAL
LIPODISSOLVE
LIPOSUCTION: (type)
_____________________
_____________________
MASSAGE THERAPY
MESOTHERAPY
MICRODERMABRASION
NUTRITIONAL COUNSELING
PERMANENT MAKEUP
SCLEROTHERAPY
THERMAGE
OTHER PROCEDURES NOT NOTED ABOVE (Continue to specify individual performing)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Page 13 of 14
14. Have all staff performing procedures noted on the previous page received a minimum of 8
hours training specific to the indicated procedure including anatomy, physiology,
technique, potential complications, appropriate responses to complications, and hands-
on performance of at least one procedure on a live patient? Please attach evidence of
training for aesthetic procedures noted.
Yes No
15. Does the applicant or staff utilize or perform any procedures, drugs, or equipment that is
not approved for use by the FDA? If yes, please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Yes No
16. Does the applicant or staff engage in any off label use of otherwise FDA approved
procedures, drugs, or equipment? If yes, please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Yes No
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA 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.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
Page 14 of 14
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and
made a part of this application.
Applicant:
_____________________________________
Title:
________________________________
FEIN #:
_____________________________________
Applicant’s Signature:
___________________________
Date:
________________________________
Agent / Broker Name:
______________________________________________________________________
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AH CLINIC MEDICAL SPA COMBO 1 (Kinsale Insurance)

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Completed 16 July 2020

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