Transcription of HUMAN SERVICES RENEWAL SUPPLEMENT - PHLY
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Example: bachelor of science
HUMAN SERVICES RENEWAL SUPPLEMENT - PHLY
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 Aides Medical Directors (Admin.)
1. If the Applicant is requesting primary medical professional coverage for any of above noted Physicians, Psychiatrists, Dentists or Opticians, the Applicant must submit a completed and signed Medical Professional
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