By Chad Perkins,2014-06-28 08:27
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     ADMIRAL INSURANCE COMPANY MEDICAL SPA 6455 East Johns Crossing, Suite 240 SUPPLEMENTAL Duluth, GA 30097 (TO BE USED WITH OUR MISCELLANEOUS MEDICAL Phone: 770-476-1561 ? Fax: 770-418-9597 APPLICATION)


    All questions must be fully completed. If there is insufficient space to complete an answer, continue on a separate sheet of paper.

1. Full name of applicant: _______________________________________________________________________

    2. Provide a list of the Applicant’s Medical Director(s): _______________________________________________


3. Attach a CV for each of the Applicant’s Medical Directors and a description of their duties.

    4. Provide the percentage of the Applicant’s patients/clients in the following categories:

     Beauty Shop (nails, hair, facials) _____% Patient/Client Ages

    Dental _____% Less than 12 years old _____%

     Massage _____% 12 to 18 years old _____%

     Medical Spa/Anti-Aging _____% Greater than 18 years old _____%

     Research or Experimental _____% Total 100 %

     Surgical _____%

     Weight Control _____%

     Other (specify)________________ _____%

     Total 100 %

5. Professional Services

     a. List all manufactured equipment in the Applicant’s practice and the purpose for which each I used:




    b. Provide the following information for each type of procedure that is performed and attach a TRAINING



    Prodedure Performed By (Include Is Training Is CV Is Client Selection Is Informed Number of

    name of all individuals Certificate Attached Protocol Attached? Consent Attached? Procedures

    performing each prodedure) Attached (Yes/No) (Yes/No) (Yes/No)


    Acne Blue Light Treatment

    Botox Injections Chemical Peels Specify Solution

    Strength _______

    Electrolysis Hair Transplants Laser Hair Removal

    Laser Skin Treatment Specify

    Type __________

    Massage Microdermabrasion Other injections Specify type (fat,

    collagen, silicone)


    Permanent Makeup/


    Other ________________

c. Are any of the procedures listed in question 5 above performed by a physician or dentist? _____Yes _____ No

    If Yes, do all physicians and dentists carry Professional Liability Insurance? _____ Yes _____ No

d. Do you perform:

     i Acupuncture or acupuncture anesthesia? Explain _____________________________ ___ Yes ___ No

     ii Anglography/arteriography/venography? Describe ____________________________ ___ Yes ___ No

     iii Catheterization (other than urinary or umbilical)? Describe______________________ ___ Yes ___ No

     iv Closed reduction of compound fractures and/or normal deliveries and/or dermabrasion? ___ Yes ___ No

     v Injection of radioisotopes and/or use of irradiated substances? Describe ____________ ___ Yes ___ No


     vi Radiation therapy and/or chemotherapy? Describe _____________________________ ___ Yes ___ No

     vii Psychiatric shock therapy? ___ Yes ___ No

     viii Silicone injections? Describe ______________________________________________ ___ Yes ___ No

     ix Spinal anesthesia (other than saddle blocks or caudals)? ___ Yes ___ No

     x Laser treatment? Describe ________________________________________________ ___ Yes ___ No

     xi Experimental procedures or research testing? Describe in detail on a separate sheet ___ Yes ___ No

     xii Hypnosis? Describe _____________________________________________________ ___ Yes ___ No

e. Do you perform:

     i Norplant insertion/removals? Advise number yearly ___________________________ ___ Yes ___ No

     ii Surgery other than incision of superficial boils or suturing superficial fascia? ___ Yes ___ No

     iii Circumcisions and/or dilation and curettage and/or insertion of temporary pacemaker? ___ Yes ___ No

     iv Tonsillectomies and/or adenoidectomies and/or caesarian sections? ___ Yes ___ No

     v Cosmetic plastic surgery? Describe ________________________________________ ___ Yes ___ No

     vi Excision of large cysts and/or I&D of deep-seated boils or carbuncles? ___ Yes ___ No

     vii Hysterectomies? ___ Yes ___ No

     viii Open reduction of fractures? Describe ______________________________________ ___ Yes ___ No

     ix Surgery for weight reduction of patients? ___ Yes ___ No

     x Abortions and/or menstrual extractions? Describe (include trimester, method and

    number of abortions performed per month) __________________________________ ___ Yes ___ No

     xi Cryosurgery (other than use on benign or pre-malignant dermatological lesions? ___ Yes ___ No

     xii Silicone implants? Describe ______________________________________________ ___ Yes ___ No

     xiii Sterilization procedures? Describe _________________________________________ ___ Yes ___ No

     xiv Biopsies and/or endoscopies? List types performed ____________________________ ___ Yes ___ No

     xv Sex change operations? Describe and advise number yearly _____________________ ___ Yes ___ No

     xvi Experimental surgery or surgical research? Describe in detail on separate sheet ___ Yes ___ No

     xvii Other surgery? Describe: _________________________________________________ ___ Yes ___ No

    f. i Do you perform or engage in any surgical procedure(s) in your professional office or

    similar non-hospital facility? ___ Yes ___ No

    ii List ALL surgical procedures performed (including minor surgery) _______________



     iii Do you administer anesthesia (other than topical or local infiltration)? ___ Yes ___ No

    g. Do you perform hospital emergency room care for patients not your own? ___ Yes ___ No

     If yes, please attach detailed explanation.

     i Emergency Room Physicians _____ hrs. iii Nurses _____ hrs.

     ii Paramedics _____ hrs. iv Other _________________ _____ hrs.

h. Do you use drugs for weight reduction or patients? ___ Yes ___ No

     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.

i. Do you administer any methadone treatment? ___ Yes ___ No

     If yes, please attach description of treatment and controls used and indicate number of

     Treatments during: Last 12 months ___________ Next 12 months ________________

    j. Number of annual x-ray exposures: for diagnosis ______________ for treatment ___________

    k. If x-ray treatment is given, what qualifications are required of the staff? _______________ ___ Yes ___ No


    l. Do you participate in any activity, e.g. newspaper columns, broadcasts, etc., in which

     professional advise is offered to the public? If yes, please attach detailed explanation of

     this activity. ___ Yes ___ No

    m. Attach detailed description of any additional activities and/or procedures which you performed.

6. Staff

     a. Does the Applicant employ anyone? _____ Yes _____ No

     If Yes, indicate by profession the number of individuals employed:

     _____ Anesthetician _____ Registered Nurse

     _____ Electrologist _____ Technician (specify type) ________________________________

     _____ Massage Therapist _____ Other (describe) _______________________________________

    b. Does the Applicant supervise anyone other than its own employees? _____ Yes _____ No

     If Yes, Indicate by profession the number of individuals supervised:

     _____ Anesthetician _____ Registered Nurse

     _____ Electrologist _____ Technician (specify type) ________________________________

     _____ Massage Therapist _____ Other (describe) _______________________________________

    c. Please indicate the number of professional employees volunteers and independent contractors. IF NONE,


     Employees Independent Employees Independent

    & Contractors & Contractors

    Volunteers Volunteers Physicians: No surgery (other Anesthesiologists, Thoracic than incision of boils, Surgeons, Vascular Surgeons suturing of skin) or obstetrical Neurosurgeons, and procedures _________ __________ Orthopedic Surgeons _________ __________ Physicians: Minor surgery or Physicians & Surgeons obstetrical procedures not Assistants, Nurse constituting major surgery Practitioners (describe duties

    _________ __________ on separate sheet _________ __________ Proctologists, Ophthalmologists and Unlicensed Interns _________ __________ Urologists, General Surgeons, Cardiac Surgeons, and Otolaryngologists (no plastic Dentists (no oral surgery) _________ __________ surgery) _________ __________

    Obstetrics-Gynecologists, Plastic Surgeons, and Orthodontists _________ __________ Otolaryngologists _________ __________

    Oral Surgeons _________ __________ Podiatrists _________ __________ Nurse Anesthetists _________ __________ Chiropractors _________ __________ Optometrists, Opticians _________ __________ Therapists _________ __________ Pharmacists _________ __________ Other ___________________ _________ __________ Perfusionists _________ __________ Other ___________________ _________ __________

    Also indicate by profession the number of individuals supervised.

    Number Type of Profession Number Type of Profession

    ________ Physicians _______ __________________________

    ________ X-ray Technicians _______ __________________________

    ________ Laboratory Technician _______ __________________________

WARRANTY: I/We warrant to the Insurer, that I understand and accept the notice stated above and that the information

    contained herein is true and that it shall be the basis for the policy of insurance and deemed incorporated therein, should

    the Insurer evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim

    information from any prior insurer to Admiral Insurance Company, Underwriting Manager for the Company.

_________________________________________ _____________________________________________

    Name of Applicant Title (Officer, partner, etc.)

_____________________________________________ __________________________________________________

    Signature of Applicant Date

    SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete this insurance, but one copy of this application will be attached to the policy, if issued.

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