Laserfiche WebLink
From: 7146416612 Page: 2/4 Date: 511109 3:16:53 PM <br />Buslneas Risk Poitners. ANsrrra" Dispute ft okldon 10mbasiarwis Lidit /1olk*llwn 1 IM <br />WWW,RU81,Vr :ElSRIZKPAAT`417"3 GUM <br />BUS INE:S5RISKPARTNERS <br />Cx, rr J.. -M. trporx -es <br />IQPO k' 1 + BAND AvXMrrr' OW 10 * Li.. SMU7DO, CA 0024, <br />F"La: gio-a22. -ijot • r'.NZ: + 12a �`.5 3 - o.c7c7u• <br />As 7ffkJRUm <br />ODMp09 tip apQEf zbm by sow w alkVtow iuyiiiuu di"we ". &wGrw Fr M u 'wt-06. % F emp1w ww <br />alppikallon end a oOng the Morn ubw by harrd. VW irlf abed Adobe AC Mbar tWWW Veralon 4.0 tilt rAA$AYM A.) M You an <br />tWN vwdm 3,0, you can upgrade it for tree at www.adobe.cam. Fax, mail, or w=1 the oampMaied app9aMm b euwt <br />Risk Partners at the sddm a rK*W above. <br />1- Name of AppifoanL <br />C <br />Phone: <br />2. Entail Address: <br />Wabsits Address: <br />3. ApplkaM is: *twdividual 0 Finn <br />4. F%w" indicate ft W* number of full and part tirne Aditvtbom: 7"7m <br />(Thb krdudm Prh le AKlg" & A dpe Pro tears) <br />5. Pleaea indicate the total number of tuff and pa"me Miedtat=: <br />(This km Waa Fad Fkrdan, Relates,. Special Masiars and NK" t vak l) <br />6. Do you spar►d amore than 20 hours per week providing ASR services? <br />6U 6CftC. <br />Fiber) <br />13 Yos )<No <br />7. Are nwe that(1 t% of your ADR services in 1 he area of Family Mediation or Consumer ADR? <br />Q YesXNo <br />6. a. Have any professional liability otal t(s) or suits ever been mach agahM to Appfbcent, or any <br />directors, officers or ampioyees? Cl Y" ?(No <br />b, Have t wy ever boon the subject of disciplinary or ariminai actions as a result of their prohnsimwil <br />ac4iww"? D Yea )kNo <br />8. Does the Applicant or do any directors, offers or employees have any knowWge of an y act, e <br />omf Ion, or pars rW injury, wtkh might reasonably give rWe to a claim? 0 Yes No <br />If Yes, please describe or attach tletalied informartion: <br />it is undarsbood and agreed that if the snsvwer to questions Or 9 is "Yes'. any such claim or polanlW <br />Claim is specifically excluded from this proposed coverage. <br />