Aesthetica Form – The White Choice

Source of Enquiry *

Policy name including any applicable trading names and/or limited companies:

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Director/Proprietor's full name: *

Director/Proprietor's contact number: *

Director/Proprietor's email address: *

Director/Proprietor's date of birth: *//

Director/Proprietor's full address: *

Address Line 1

Address Line 2

City/Town

County

Postal Code

Client Banding: *

Please select your client banding.

Have you ever held medical malpractice insurance? *

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When does your current insurance expire? *

What is your current renewal premium? *

All prices in GPB (£).

What insurer are you currently with? *

What is your retroactive date? *

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What level of cover do you require? *

Please select your required level of cover.

Do you require training cover? *

Please select whether you require training cover.

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Medic PIN Number: *

Type of registration: *

Registration date: *

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What training have you undertaken? *

Please provide information of any training you have undertaken.

Do you hold a level 3 NVQ in Beauty or equivalent? *

Please provide information of any beauty National Vocational Qualifications that you hold.

Please provide a full list of training and experience: *

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Do you require contents insurance? *

Do you require employers liability insurance? *

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Type *

Stock
General contents
Tennants improvements
Computers and machinery
Property away from the office UK

PLEASE NOTE: Maximum single item value is GBP £25,000.

Amount entered is sum insured.

Stock *

All prices in GBP (£).

General contents *

All prices in GBP (£).

Tennants improvements *

All prices in GBP (£).

Computers and machinery *

All prices in GBP (£).

Property away from the office UK *

All prices in GBP (£).

Wage Roll *

All prices in GBP (£).

Employer Reference Number (ERN): *

Please enter your Employer Reference Number (ERN).

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Treatments

Band 1 - Beauty Therapy
Band 1 - Advanced Beauty

What's included with:

- Doctor, Nurse, Dentist, Dental Therapist, Dental Hygienist, Pharmacist, Physiotherapist, Operating Department Practitioner, Paramedic, Beautician ( NVQ level 2 & 3), Dental Nurse
- Allergy testing (patch and skin prick testing)
- Application of branded third party skin care products
- Body wrapping
- Chemical Peels up to 40% acid strength
- Ear and body piercing excl genitals
- Electrolysis for hair removal and thread veins
- False eyelash application
- Hairdressing and barbering
- LED light therapy
- Makeup and spray on tan application
- Massage
- Nail extensions and treatments
- Temporary hair removal and bleaching

N.B. The provision of training to other practitioners for treatments in thes categories is included.

- Doctor, Nurse, Dentist, Dental Therapist, Dental Hygeinist, Pharmacist, Physiotherapist , Operating Department Practitioner, Paramedic, Beautician (NVQ level 3), Dental Nurse
- Advanced Electrolysis
- BB Glow
- Chemical Peels excl. Phenol
- Colonic hydrotherapy
- Cryopen, cryolypolysis, cryotherapy for aesthetic purposes, cryotherapy chamber for wellness
- Dermaplanning / Dermablanning
- Electrical facial treatments
- HIFU
- Hydradermabrasion
- Hydrafacial
- Mesotherapy device
- Micordermabrasion
- Microblading
- Microneedling device
- Micropigmentation
- Microsclerotherapy/Sclerotherapy
- No needle mesotherapy
- Phlebotomy
- Radiofrequency
- Ultrasounds for aesthetic purposes

N.B. The provision of training to other practitioners for treatments in thes categories is included

Treatments
Annual Turnover Figure (GBP) Per Banding for:

Beauty Therapy *

Advanced Beauty *

Total

£ 0.00

Training
Annual Turnover Figure (GBP) Per Banding for:

Beauty Therapy

Advanced Beauty

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Treatments

Band 1 - Injectables
Band 1 - Specialist

Please select any relevant treatments from the lists below.

Treatments
Annual Turnover Figure (GBP) Per Banding for:

Injectables *

Specialist *

Total

£ 0.00

Training
Annual Turnover Figure (GBP) Per Banding for:

Injectables

Specialist

Treatments in the following bands need to be confirmed and will be listed on the quote/policy document.
Please select any required treatments for selected bands below:

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Band 1 - Injectables *

Botulinum toxin
Non permanent dermal fillers
Injectable skin boosters and sculpting
Medical needling
Mesotherapy
PRP
Hyalase / Hyaluronidase
Local Anaesthetic applications for Aesthetic Treatments
Vitamin Infusion Therapy and Intramuscular vitamin injections
Eyelash growth prescriptions
Aesthetics prescriptions
Fat dissolving injections
Microneedling and Radiofrequency combined
Weight loss programmes (diet and body contouring)
The provision of training to other practitioners for treatments in this category

Doctor, Nurse, Dentist, Dental Therapist, Dental Hygienist, Pharmacist, Physiotherapist , Operating Department Practitioner, Paramedic.

Band 1 - Specialist *

Chemical Peels incl up to 10% Phenol
Non steroid joint injections
Kenalog for Hayfever or joints
The provision of training to other practitioners for treatments in this category

Doctor, Nurse.

Additional information regarding the risk that you feel we should be made aware of / Treatments not listed above.

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Treatments

Band 2
Band 3
Band 4

Please select any relevant treatments from the lists below.

Treatments
Annual Turnover Figure (GBP) Per Banding for:

Band 2 *

Band 3 *

Band 4 *

Total

£ 0.00

Training
Annual Turnover Figure (GBP) Per Banding for:

Band 2

Band 3

Band 4

Treatments in the following bands need to be confirmed and will be listed on the quote/policy document.
Please select any required treatments for selected bands below:

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Band 2 *

IPL/ non ablative laser
Superficial Plasma treatments
Dissolveable thread lifts (Mono and screw only)
Chemical tattoo removal
Bio Identical Hormones
Minor Surgery removal/excision, Non-malignant mole removal/excision, hair from mole, Sebaceous cyst removal, Skin tag removal, Skin lesion/non-cancerous etc.
The provision of training to other practitioners for treatments in this category

Band 3 *

IPL/ ablative laser
Vaginal HA fillers
Macrolane
Vaginal laser/RF
Ear lobe correction
Weight loss Prescribed Injectable i.e. Saxenda /Ozempic/ Orilstat
O&P shot
Cellfina
The provision of training to other practitioners for treatments in this category

Doctor, Nurse.

Band 4 *

Hair Transplant
Vaser
Bodytite
Subdermal Plasma (J plasma)
Blepharoplasty
The provision of training to other practitioners for treatments in this category

Doctor.

Additional information regarding the risk that you feel we should be made aware of / Treatments not listed above.

Please review your submission before submitting.

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Total annual turnover submitted:

£ 0.00

M - SP

Do you provide treatments on a mobile basis or from a rented room or chair within a third party clinic? *

Are all patient records, including details of services provided, retained for at least ten years? *

Are you qualified and/or certified to perform each of the treatments you offer? *

Do you always undertake skin patch tests where recommended by the manufacturer of any product used and before any treatment? *

Can you confirm that you do not alter, re-package or re brand these products in anyway? *

Do you retain full rights of recourse against the supplier and or manufacture of this product? *

Have you got a process in place to update your COVID-19 procedures in line with COVID-19 guidance issued by Public Health England or any other health authority or body authorised to provide public health guidance? *

Can you confirm that you are not aware of any incident, any injury or illness to a patient or escalating complaint that could lead to you needing to make a claim on this insurance? *

I can confirm that I have never offered, or do not currently offer, services to any of the following: a) Celebrities b) High Profile Individuals; or c) Persons who generate income from social media platforms or applications *

Is all your work undertaken within the UK? *

Do you take before and after photographs in respect of a; botulinum toxin and dermal filler treatments to the head and neck b; laser treatments other than laser treatment where the treatment area is the genitalia? *

Do you hold a current license to practice with one of the following UK licensing bodies : GMC; GDC; NMC; HCPC; GPhC? *

Do you only supply third party proprietary beauty and aesthetic products? *

Are all products sourced from third party distributors or manufacturers in the UK, European Union, Japan, Australia, New Zealand, USA and Canada? *

Can you confirm that no investigation or disciplinary proceedings have been made against you by your professional body? *

Have you carried out a detailed risk assessment of your business to identify and minimise the risks posed by Covid 19 and implemented any necessary changes? *

Can you confirm that you have not: a) In the past 10 years, been declared bankrupt or insolvent either in a personal capacity or in connection with a business liability b) Been disqualified from acting as a director of a limited company or member of a limited liability partnership c) Been convicted of, or charged with, a criminal offence other than a conviction spent under the Rehabilitation of Offenders Act 1974 d) Had an insurance policy cancelled by the insurer e) Ever suffered any claim or loss that would fall within the scope of this insurance. *

Are all SOF questions (ignoring Q1) ‘Yes’? If not, please provide further details. *

NM - SP

Do you provide treatments on a mobile basis or from a rented room or chair within a third party clinic? *

Do you keep client records, including details of services provided, for at least 10 years? *

Are you qualified and/or certified to perform each of the treatments you offer? *

Have you completed a training course in Botulinum Toxin which included a face to face practical assessment of your competency? *

Do you always undertake skin patch tests where recommended by the manufacturer of any product used and before any treatment? *

Do you only supply third party proprietary beauty and aesthetic products? *

Are all products sourced from third party distributors or manufacturers in the UK, European Union, Japan, Australia, New Zealand, USA and Canada? *

Can you confirm that you are not aware of any incident, any injury or illness to a patient or escalating complaint that could lead to you needing to make a claim on this insurance? *

Is all your work undertaken within the UK? *

Have you completed a training course in Dermal Fillers which included a face to face practical assessment of your competency? *

Prior to removing any human tissue, mole, tag, tumour or other form of human growth or cell, as part of any treatment, please confirm that: - written consent from a qualified and UK licensed medical practitioner, that the relevant treatment area is non cancerous, is obtained; and - this documentation retained with a patient's record? Please note that your policy contains a coverage exclusion in the event that written consent is not documented. *

Do you only undertake Botulinum Toxin treatments once a medical practitioner, with a licence to prescribe in the UK, has prescribed the product following a visual consultation and an informed consent process with the patient? *

Can you confirm that you do not alter, re-package or re brand these products in anyway? *

Do you retain full rights of recourse against the supplier and or manufacturer of this product? *

Have you carried out a detailed risk assessment of your business to identify and minimise the risks posed by Covid 19 and implemented any necessary changes? *

Can you confirm that you have not: a) In the past 10 years, been declared bankrupt or insolvent either in a personal capacity or in connection with a business liability; b) Been disqualified from acting as a director of a limited company or member of a limited liability partnership; c) Been convicted of, or charged with, a criminal offence other than a conviction spent under the Rehabilitation of Offenders Act 1974; d) Had an insurance policy cancelled by the insurer; e) Ever suffered any claim or loss that would fall within the scope of this insurance *

Are all SOF questions (ignoring Q1) ‘Yes’? If not, please provide further details. *

M - C

Is all your work undertaken within the UK? *

Are photographs taken before and after treatments in respect of a; botulinium toxin and dermal filler treatments to the head and neck and b; all laser treatments, other than where the treatment area is the genitalia? *

Are you, all staff and all individuals you engage with to offer treatment/s qualified and/or certified to perform each of the treatments you offer? *

Do you, all staff and all individuals you engage with to offer treatment/s always undertake skin patch tests where recommended by the manufacturer of any product used and before any treatment? *

Can you confirm that you do not alter, re-package or re brand these products in anyway? *

Do you retain full rights of recourse against the supplier and or manufacture of this product? *

Can you confirm that you are not aware of any incident, any injury or illness to a patient or escalating complaint that could lead to you needing to make a claim on this insurance? *

Are all patient records, including details of services provided, retained for at least ten years? *

Do you perform due diligence on all staff and any other individuals before engaging with, or employing, them to offer services? *

Do you, all staff and all individuals you engage with to offer treatment/s hold a current license to practice with one of the following UK licensing bodies : GMC; GDC; NMC; HCPC; GPhC? *

Do you only supply third party proprietary beauty and aesthetic products? *

Are all products sourced from third party distributors or manufacturers in the UK, European Union, Japan, Australia, New Zealand, USA and Canada? *

Can you confirm that no investigation or disciplinary proceedings have ever been brought by a professional body against you, all staff and all individuals you engage with? *

Have you carried out a detailed risk assessment of your business to identify and minimise the risks posed by Covid 19 and implemented any necessary changes? *

Can you confirm that neither you or any of your directors or partners have: a) In the past 10 years, been declared bankrupt or insolvent either in a personal capacity or in connection with a business liability b) Been disqualified from acting as a director of a limited company or member of a limited liability partnership c) Been convicted of, or charged with, a criminal offence other than a conviction spent under the Rehabilitation of Offenders Act 1974 d) Had an insurance policy cancelled by the insurer e) Ever suffered any claim or loss that would fall within the scope of this insurance. *

NM - C

Is all your work undertaken within the UK? *

Are you, all staff and all individuals you engage with to undertake treatment/s qualified and/or certified to perform each of the treatments you offer? *

Have you, all staff and all individuals you engage to undertake Botulinum Toxin treatments completed a training course in Botulinum Toxin which included a face to face practical assessment of competency? *

Do you, all staff and all individuals you engage with, only undertake Botulinum Toxin treatments once a practitioner, with a licence to prescribe in the UK, has prescribed the product following a visual consultation and informed consent process with the patient? *

Do you only supply third party proprietary beauty and aesthetic products? *

Are all products sourced from third party distributors or manufacturers in the UK, European Union, Japan, Australia, New Zealand, USA and Canada? *

Can you confirm that you are not aware of any incident, any injury or illness to a patient or escalating complaint that could lead to you needing to make a claim on this insurance? *

Are all patient records, including details of services provided, retained for at least ten years? *

Do you perform due diligence on all staff and any other individuals before engaging with, or employing, them to offer services? *

Have you, all staff and all individuals you engage to undertake Dermal Fillers completed a training course in Dermal Fillers which included a face to face practical assessment of competency? *

Do you, all staff and all individuals you engage with always undertake skin patch tests where recommended by the manufacturer of any product used and before any treatment? *

Prior to removing any human tissue, mole, tag, tumour or other form of human growth or cell, as part of any treatment, do you: - obtain written consent from a qualified and UK licensed medical practitioner, that the relevant treatment area is non cancerous; and - retain this documentation with a patient's record? Please note that your policy contains a coverage exclusion in the event that written consent is not documented. *

Can you confirm that you do not alter, re-package or re brand these products in anyway? *

Do you retain full rights of recourse against the supplier and or manufacture of this product? *

Have you carried out a detailed risk assessment of your business to identify and minimise the risks posed by Covid 19 and implemented any necessary changes? *

Can you confirm that neither you or any of your directors or partners have: a) In the past 10 years, been declared bankrupt or insolvent either in a personal capacity or in connection with a business liability; b) Been disqualified from acting as a director of a limited company or member of a limited liability partnership; c) Been convicted of, or charged with, a criminal offence other than a conviction spent under the Rehabilitation of Offenders Act 1974; d) Had an insurance policy cancelled by the insurer; e) Ever suffered any claim or loss that would fall within the scope of this insurance. *

Are all SOF questions ‘Yes’? If not please provide further details. *