The Crawford Insurance Group > Customer Resources > Get a Quote

Mailing Address

Location Address

Telephone Number
Area CodePhone Number
Fax
Area CodePhone Number
Website Address
Date Established
Month / Day / Year
Entity Type
Corp
Partnership
Professional Association
Individual
Desired Effective Date
Month / Day / Year
Desired Limits of Liability
Desired Deductible
Gross Receipts for Past 12 Months
Est. Gross Receipts for Next 12 Months
Payroll for Past 12 Months
Est. Payroll for Next 12 Months
Does the applicant have any ancillary operations?
Yes
No
Please provide details
Is the firm engaged in, owned by, associated with or controlled by any other business?
Yes
No
Please provide details
What was your total number of patient/client visits last year?
Estimated Next Year?
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Employees/Contractors
List the number and type of applicant's employees currently including estimated over the next 12 months. If none, state none.

Employees

Employees

Blank	Number
Physician (patient contact)
Physician (medical director only)
Laser Technician
CRNA/Surgical Technician
Massage Therapist
Chiropractor
Clerical/Admin

List the number and type of independent contractors estimated over the next 12 months. If none, state none.

Contractors

Contractors

Blank	Number
Physician (patient contact)
Physician (medical director only)
Laser Technician
CRNA/Surgical Technician
Massage Therapist
Chiropractor
Clerical/Admin

Are all the above individuals listed in response to question 12a & b licensed in accordance with applicable state and federal regulations
Yes
No
If no, attach explanation.
Do you require contracted staff (if any) to carry their own Professional Liability Insurance & secure certificates of Insurance as evidence of such coverage?
Yes
No
If yes, at what limits?
If no, is coverage desired with shared limits on this policy?
Yes
No
Do you require employed physicians, surgeons, nurse anesthetists, dentists, podiatrists or chiropractors to carry their own Professional Liability Insurance and secure Certificates of Insurance as evidence of such coverage?
Yes
No
If yes, at what limits?
Who is the Medical Director?
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If you lease a space please answer below:

Blank	Please Answer
How many square feet?
Year of last roof replacement?
Year of last HVAC replacement?
Year of last electrical replacement?
What is the value of the property that the Spa Owns?
How much of that property has to be temperature controlled?

Blank	Yes	No
Do you conduct pre-employment screening and investigation?
Do you question prospects about previous claims or suits?
Are employees required to actively participate in continuing education?
Do you prepare job descriptions and instructional manuals for your staff?
Do you have a written incident/occurrence reporting policy and procedures?

Medical Spa Application