specialty application- victor o. schinnerer（专业应用程序——维克多·o·schinnerer）（9页）.docVIP

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specialty application- victor o. schinnerer（专业应用程序——维克多·o·schinnerer）（9页）.doc

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Application for Specialty Construction Consultants Professional Liability Coverage New Application Schinnerer Use Only Renewal Application ISN: ????? Renewal Policy #: ????? Broker #: ????? NOTE: The insurance coverage for which you are applying is written on a CLAIMS-MADE AND REPORTED policy. Only claims which are first made against you and reported to us in writing during the policy period are covered, subject to policy provisions. The Limits of Liability stated in the Policy are reduced by the cost of defense. Legal defense costs also may be applied against your Deductible, if applicable to the Claim. Please consult your policy directly for specific coverage. If you have any questions about the coverage, please discuss them with your insurance agent or broker. Please indicate the limits(s) you wish us to quote: $????? Please indicate the deductible(s) you wish us to quote: $????? FIRM INFORMATION Please list all persons or entities for which you are seeking coverage and describe the relationship and ownership of each listed person or entity on a separate sheet. Please also list the addresses of all branch offices. 1. Principal Firm Name: ????? Address: ????? Contact Name: ????? City: ????? Contact Email: ????? State: ????? Zip: ????? County: ????? Phone: ????? Fax: ????? Website URL: ????? Partnership LLC Sole Proprietorship Corporation Professional Corporation Subchapter S Corporation Other: ????? Tax ID #: ????? Year Firm Established: ????? 2. Indicate the numbers of licensed professionals in each category: Architects Engineers Land Surveyors Landscape Architects Geologists Hydrologists Industrial Hygienists Other Principals, Partners, Officers Directors ????? ????? ????? ????? ????? ????? ????? Staff ????? ????? ????? ????? ????? ????? ????? Total Licensed ????? ????? ????? ????? ????? ????? ????? Total Number of Employees: ????? Number of professional or management staff or principals that left th