1.  APPLICANT INFORMATION
Name of Applicant:
Clinic Address: County:
City: State: Zip:
Business Phone: Franchise Number:

Full name and address of additional locations seeking coverage under one policy
(for separate policies, please complete a separate application for each location.)

Name of Additional Location:
Clinic Address: County:
City: State: Zip:
Business Phone:
2.  OPERATIONS
Please state total annual revenue:
  Amount Last 12 Months Amount Next 12 Months
Location #1
Location #2
Is coverage desired for the Franchisor - Massage Envy, LLC as Additional Insured?
Yes No
Are any Products Sold?
Yes No
If yes, please provide name and manufacturer of each:

3.  List the number of your employees and volunteers.
Number Type of Employees/Volunteers
Are all of the above individuals licensed in accordance with applicable state and federal regulations?
Yes No
Do you have evidence of current licensing information on file for each Massage Therapist
Yes No
Do you require evidence of each Massage Therapist's Professional Liability Insurance
Yes No
Please indicate professional societies or association in which you are a member:
Do you supervise any individuals other than your own employees?
Yes No

4.  SERVICES
Type of Massages /
Other treatments

# of treatments
annually
Percentage
Age ranges:
Acupuncture
Cranio-Sacral Therapy
Infant Massage
Lymphatic Massage
Maternity Massage
Reflexology
Reiki
Shiatsu
Thai Massage
Other (describe)


5. BUSINESS ASSOCIATIONS
Do you provide services under the direction of a physician, chiropractor or naturopathic physician?
Yes No
If yes, please give name and address of that physician, chiropractor or naturopathic physician:
Do you own or operate any business other than that shown in Question 1 above?
Yes No
If yes, please give details on separate sheet.
Are you employed by or under contract to any individual or entity other than that shown in Question 1 above?
Yes No
If yes, please attach a copy of the contract or include details of your responsibilities

6. APPLICANT HISTORY
PLEASE FILL DETAILED EXPLANATION FOR ANY "YES" ANSWERS.

a.  Have you or any of your employees:
(i) Ever been the subject of disciplinary or investigatory proceedings or reprimanded by an administrative or government agency, hospital or professional association?
Yes No
Detailed Explanation:
(ii) Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?
Yes No
Detailed Explanation:
(iii) Ever been treated or are currently being treated for alcoholism or drug addiction?
Yes No
Detailed Explanation:
(iv) Ever had any state professional license refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered same?
Yes No
Detailed Explanation:
(v) Ever had any insurance company or Lloyd's cancel, decline, refuse to renew or accept only on special terms their malpractice insurance?
Yes No
Detailed Explanation:
b. Has any claim or suit been brought against you and/or any of your employees?
Yes No
If yes, a supplemental claim information must be completed for each claim or suit.
Detailed Explanation:
c. Are you aware of any circumstances which may result in a claim or suit being made or brought against you or any of your employees?
Yes No
Detailed Explanation:
d. List prior Professional Liability Insurance carried for each of the past three years. IF NONE, STATE NONE.
Insurance Carrier #1:
Policy Number:
Limits of Liability:
Deductable:

Premium:
Inception Exp.
Mo./Day/Yr.
Claims Made
Policy Form?
Yes No
Retroactive
Date:


Insurance Carrier #2:
Policy Number:
Limits of Liability:
Deductable:

Premium:
Inception Exp.
Mo./Day/Yr.
Claims Made
Policy Form?
Yes No
Retroactive
Date:


Insurance Carrier #3:
Policy Number:
Limits of Liability:
Deductable:

Premium:
Inception Exp.
Mo./Day/Yr.
Claims Made
Policy Form?
Yes No
Retroactive
Date:


e. List current General Liability Insurance
Insurance Carrier:
Policy Number:
Limits of Liability:
Deductable:

Premium:
Inception Exp.
Mo./Day/Yr.
Claims Made
Policy Form?
Yes No
Retroactive
Date:


*NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.

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 of 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 Lapre Scali & Comany Insurance Services, LLC, Underwriting Manager for the Company.

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


SUBMITTING this application does not bind the applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued. (Claims Made Basis)

24/48 turn around for quotes
Lapre Scali & Company team consists of Sara Gromek and Rena Bell that are here to answer all questions immediately.

Massage Envy Limited, LLC will be added as an additional insured but only in respect to operations of the named insured at no additional expense to franchisee owner.

Limits offered for Professional liability are 1 million per claim and $3 million aggregate limit with a $2,500 Deductible- Defense outside the limits included with an additional 10% of the premium.

Toll Free: 1-877-995-2773 (1-877-99-Lapre)    |    Bond Dept: 1-800-863-3210    |    Fax: (480) 947-6699
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