Social Services Organization Supplemental Application

Insured Information








  1. Number of years this facility has been:




General Liability Section:


  1. Was a claim made against the organization?



    Was a claim made against any employee(s)?



    If yes, is that individual still employed with your organization?



Professional Liability

  1. Is Professional Liability…


  2. Position # of Full Time # of Part Time
    Administrators
    Counselors (Including Group Home Manager)
    Psychologists
    Nurses R.N.
    Nurses L.P.N.
    Home Health Aides
    Social Workers
    Clerical
    Teachers
    Physicians
    Psychiatrists
    Therapists

  3. Do the physicians carry their own malpractice insurance?





Submission
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