Consultants Supplement Consultants Supplement Consultants Supplement Specified Professions Professional Liability Product SUPPLEMENT TO THE SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION FOR MANAGEMENT/HUMAN RESOURCES/MARKETING CONSULTANTSApplicant's Name:* Prefix First Last Suffix If the Applicant is newly established, please provide best estimates. 1. Please provide a percentage breakdown of current 12 month Gross Receipts from the following: (Provide description of services for all that apply)Management Consulting:%Description of Services:Human Resources Consulting:%Description of Services:Marketing Consulting:%Description of Services:Other:%Description of Services:2. (If “yes”, please provide further details on the following page.) a. Does the Applicant derive over 25% of revenue from providing interim management services or to clients for whom the applicant is a board member, officer, or over 3% shareholder or as a manager on a day-to-day basis?* Yes No Details:b. Does the Applicant derive more than 25% of revenue from turnaround management services?* Yes No Details:c. Does the Applicant provide business valuation services or services as a business broker?* Yes No Details:d. Does the Applicant provide services as an investment banker, directly raising capital, or managing or issuing public/private offerings of equity or debt?* Yes No Details:e. Does the Applicant provide investment advice?* Yes No Details:f. Does the Applicant provide due diligence services for commercial loans?* Yes No Details:g. Does the Applicant provide merger or acquisition services involving structuring transactions, performing due diligence, arranging financing or facilitating the purchase or sale of the company?* Yes No Details:h. Does the Applicant provide product design, development or testing services of manufactured goods?* Yes No Details:i. Does the Applicant derive more than 25% of revenue from Sarbanes-Oxley compliance consulting?* Yes No Details:j. Does the Applicant provide engineering consulting or construction project management?* Yes No Details:k. Does the Applicant provide terrorism-related or physical security consulting?* Yes No Details:l. Does the Applicant provide real estate development or land use consulting?* Yes No Details:m. Does the Applicant provide environmental, hazardous waste or pollution consulting?* Yes No Details:n. Does the Applicant provide peer review services or services affecting healthcare treatment?* Yes No Details:o. Does the Applicant provide clinical consulting in the areas of healthcare or pharmaceuticals?* Yes No Details:p. Does the applicant provide counseling regarding the hiring or firing of specific employees for clients?* Yes No Details:q. Does the Applicant derive more than 10% of revenue from payroll-processing services (i.e. managing accounts, issuing checks, withholding taxes etc.) or subcontract these services to others?* Yes No Details:r. Does the Applicant provide benefit administration services?* Yes No Details:s. Does the Applicant derive more than 25% of revenue from the following services: Media planning/buying/production, creation, production or placement of any paid form of communication about organizations, products, or services by an identified sponsor?* Yes No Details:t. Does the applicant derive more than 10% of revenue from the design of product packaging, logos or trademarks?* Yes No Details:Details:This application is a supplement to the Specified Professions Professional Liability Application submitted by the applicant. All representations, fraud statements, acknowledgments, understandings and agreements set forth in the Specified Professions Professional Liability Application are incorporated by reference as though fully set forth herein.Signature:*TItle:* Date* MM slash DD slash YYYY Print Name:* (Please type full name in space provided)
