Final Step

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Main Business Address
Please enter street, city, state, & zip code
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Email
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Email
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City
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State
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Postal / Zip Code
CONGRATULATIONS ON RECEIVING YOUR INSTANT QUOTE! FOR YOUR FINAL APPROVAL, PLEASE ANSWER THE QUESTIONS PROVIDED BELOW. DON’T WORRY, YOUR RATES ARE LOCKED IN FOR 72 HOURS.
Name of Applicant
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Applicant Title*
Is this application for yourself as an individual or for a company?*
- Individual
- Company
Enter Company Name*
How many locations are you currently practicing at?
Please enter the address for each business location:
Enter Full Business Address*
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #2)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #3)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #4)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #5)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #6)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #7)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #8)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #9)
Please enter street address, city, state, & zip code
Enter Full Business Address (Location #10)
Please enter street address, city, state, & zip code
What year was your company established?
MM slash DD slash YYYY
Phone
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Phone
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Website Address
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Plan
Please list professional associations to which belong you to:*
- American Med Spa Association
- Empire Medical Association
- American Academy of Anti-Aging
Has your company applying today provided services to any governmental entities?*
- Yes
- No

THAT WASN’T SO BAD, LET’S KEEP GOING! ONCE THIS INFORMATION IS SENT OVER AND VERIFIED, ITS ALL ZEN FROM THERE. REMEMBER TO COMPLETE THIS BEFORE YOUR RATE EXPIRES
DO YOU CURRENTLY HAVE ANY COVERAGE FOR MEDSPA SERVICES FOR BOTOX / INJECTABLES / FILLERS? LAST 5 YEARS?*
- Yes
- No
DATE THIS POLICY WAS FIRST ACTIVE DATE
MM slash DD slash YYYY
HAVE YOU HAD ANY COVERAGE FOR MEDSPA SERVICE DURING IN LAST 5 YEARS?*
- Yes
- No
Please provide the company, expiration date, limit and premium to the best of your abilities below:
Company:
Expiration Date:
MM slash DD slash YYYY
Limit:
Premium:
Is there more than one?
- Yes
- No
Please provide the company, expiration date, limit and premium to the best of your abilities below:
Company:
Expiration Date:
MM slash DD slash YYYY
Limit:
Premium:
Please provide the total number of non-certified that will NOT be performing MedSpa procedures with Botox / Injectable and/or other Fillers and will ONLY be assisting in the practice
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Please provide the total number of professionals that will be performing MedSpa procedures with Botox / Injectable and/or other Fillers
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:
Full Name:
Professional Title:
Years in practice:
Years with:

YOU ARE ALMOST FINISHED! WE NEED A LITTLE MORE INFORMATION AND WE CAN TAKE CARE OF THE REST WITH OUR RAPID VERIFICATION PROCESS.
Have you previously or currently engaged in any business or profession other than providing MedSpa services including but not limited to Botox Injectables & Fillers procedures?
- Yes
- No
Please supply full details…
What was the total Botox / Injectable / Fillers revenue your company generated?
If you are a new startup, please enter your projected revenue for the current year. This will not affect your locked-in rates!
Current Year Botox Income*
Please provide an estimated annual projection of this year’s revenue by selecting the best case above. Remember this is only a projection (an estimate based on a business plan or pattern)
2021 Total Botox Income
2020 Total Botox Income
2019 Total Botox Income

I hereby agree this application was completed to the best of my abilities with all answers to be true and accurate in representation of the applicant.
Please execute your digital signature to complete your application:*