Transcription of HUMAN SERVICES RENEWAL SUPPLEMENT
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HUMAN SERVICES RENEWAL SUPPLEMENT
HUMAN SERVICES RENEWAL SUPPLEMENT Name Insured: Annual Revenue: $ Total Staff (including office, janitorial, maintenance, etc): Full Time: Part Time: 1. Have there been any new programs added or any changes in operations? Yes No If yes, please describe fully: 2. Risk Management Contact: Risk Management Phone: Risk Management E-mail: SECTION I - PROFESSIONAL LIABILITY PROFESSIONAL STAFFING: Total Number of: Full Time Employees: Part Time Employees: Volunteers (VOL): Staffing Employee Contracted Vol Staffing Employee Contracted Vol FT PT FT PT FT PT FT PT Counselors Psychiatrists Social Workers Physicians Hospice Occupational Therapists Pediatricians Speech Therapists Physicians Teachers Dentists Nutritionists Opticians Resident Managers Psychologists Home Health Ai
F/T = Full Time – over 20 hours per week/ P/T = Part Time – up to 20 hours per week. *Please describe “other” staff positions not listed in the above chart in the provided area.
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