1. |
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2. |
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3. |
Is the Applicant or any other proposed insured |
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(a) |
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(b) |
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4. |
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5. |
Please detail the number of partners and staff |
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(a) |
Principals/Partners/Inspectors (owners) |
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(b) |
Professional Staff /Inspectors (non-owners) |
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(c) |
Other Employees (helper/apprentices) |
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6. |
Please detail the following for all owners, officers, directors, partners and inspectors: Owner, Employee and Independent Contractor |
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7. |
Inspections by year |
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10. |
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11. |
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12. |
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13. |
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14. |
Indicate the types of inspections performed and the percentage of gross income derived from each |
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15. |
Indicate the percentage of inspections performed for the following types of clients |
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19. |
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20. |
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21. |
Does the Applicant: |
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(a) |
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(b) |
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(c) |
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(d) |
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(e) |
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22. |
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(a) |
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(b) |
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(c) |
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(d) |
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(e) |
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(f) |
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23. |
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24. |
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25. |
(a) |
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(b) |
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(c) |
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If YES to (a), (b), and/or (c), You'll need to fill the Claim/Incident/Circumstance Information Sheet for each claim.
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26. |
Limit Options: Professional Liability (Errors & Omissions) Coverage: |
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27. |
Deductible |
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28. |
Please select any additional coverages that you might want |
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