Transcription of HUMAN SERVICES RENEWAL SUPPLEMENT
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Example: dental hygienist
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 D
If the above noted employed or volunteer Physicians, Psychiatrists, Dentists or Opticians carry their own medical malpractice insurance, we may provide vicarious medical p rofessional coverage for the entity as
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