Change in business

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Do you need to update your policy?

There's been a change in your business

Having a specialty insurance product is different, let us help you by staying current with your policy! Select the primary reason you are contacting your agent today!

Please note that updates to your policy may result in additional fees if there have been changes to your business. These updates are processed as policy endorsements and are subject to underwriting review and approval.

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Email

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Account Holder's Name*

First Last

Your Account Email*

Legal Business Name (include any DBA)*

Your Policy Number

Select all of the changes that apply:*

CHANGING LOCATION

ADDING NEW LOCATION

REMOVING A LOCATION

ADDING NEW SERVICE/PROCEDURE

ADDING NEW DEVICE(S)

REMOVING A SERVICE/PROCEDURE

CHANGING MEDICAL DIRECTOR

CHANGING OWNERSHIP

CHANGING EMPLOYEES

Effective Date of Move*

When did you move to a new location or add on this new location?

MM slash DD slash YYYY

What's the address of the location you want to REMOVE?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What is the new address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

3. Will this move just be a new location to replace the old one, or a new location that will be added to existing policy?*

Replace the Existing Location

Add an Additional Location

What will you be doing new, that you’re not doing now, at your next location?*

Let us know anything else you think would be helpful in processing your request more efficiently.

Effective Date of Change*

MM slash DD slash YYYY

Do you expect an increase in your revenue?*

For example, what will your increase in revenue per month be?

Please list all new services/procedures/treatments you are requesting to add to you current policy: (Click + to List Multiple Services)*

New Service/Procedure/Treatment Offered:

Estimated procedure count for each service annually:

Please enter one service per line.

Please list all new devices you are requesting to add to you current policy: (Click + to List Multiple Devices)*

Please only enter one device per line.

New Device (Name and Model Type)

Cost of Purchase

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List all new services, procedures, or treatments you are requesting to add to a current policy.*

Let us know anything else you think would be helpful in processing your request more efficiently.

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Estimated number of procedures, services, and treatments that you plan to perform over the next 12 months*

Upload Required Documents

Training Certificates for those providing the services and Consent Forms for Patients

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Upload Required Documents*

Please upload any applicable invoices or documentation related to your New Device.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Underwriters won't refund premium for removing a service midterm but you can request a reassessment at renewal.

Let us know what service(s) you won't be including on your next renewal.*

Why are you removing this location/service/procedure?*

Medical Directors (supervising, collaborative) physicians are automatically covered per the Definition of Named Insured” in your policy. Only requirement is that they are licensed physician in your state.

New Medical Director

Full Name and Title

All employees and contractors are automatically covered, per the “Definition of Named Insured” in your policy. When the new employee is being hired to add a new service, procedure or treatment this may affect your policy.

Are you removing or adding employees?

Removing Employee

Adding Employee

Please list the employee(s) and their role that you are REMOVING: (Click + To LIst Multiple Employees)*

Employee Name

Role

Please enter one employee per line.

Please list the employee(s) and their role that you are ADDING: (Click + To LIst Multiple Employees)*

Employee Name

Role

Please enter one employee per line.

If there's been a change in ownership, a new policy order may be required. Let's get some information first.

Full Name of New Owner*

If there's a change to your Business Name, please list it below.

Was (new owner) previously involved in the business?*

Will the former owner still be involved?*

Was this a full transfer of ownership from a single 100% owner to another single 100% owner?*

Was this an asset and liability transaction or asset-only?*

Is this new location a physical address, a mailing address, or both?*

Physical Address

Mailing Address

What is the reason for the change?*

Please provide us with some context surrounding this change.

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About WMPG

The Wellness Medical Protection Group originated in 2001 as an independent insurance agency. We continue to devote ourselves to support and protect providers and businesses that seek out alternative cutting edge practices that make them so unique. We are licensed to serve you in over 35 states and specialize in Anti-Aging, Aesthetics, Alternative, Compound, & Complementary medicine. See why we are the most trusted in total practice coverage by our clients, industry leaders, and insurance providers and request a free consultation today.

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