Employment Agency Supplement Employment Agency Supplement PDF Download Employment Agency Supplement Specified Professions Professional Liability Product Name of Applicant* Prefix First Last Suffix 2. Receipts:a. Percentage of receipts generated by:* %Retained permanent placements / Executive search services:* %Contingency permanent placements / Executive search services:* %Temporary placements:* %Employee leasing / Professional employer organization:* %Other (please specify):* %Total 100%b. What percentage of receipts does the applicant derive from internet-based online job boards?*%3. a. Does the applicant use a contract with all clients?* Yes No b. If “Yes” to 3a, does the contract stipulate who is responsible for background checks of candidates for placement?* Yes No c. If “Yes” to 3a, does the contract have a hold harmless or indemnification clause in the applicant’s favor?* Yes No d. If “Yes” to 3a, does the contract have a non-binding arbitration clause for dispute resolution?* Yes No 4. a. Does the applicant provide background checks on any candidates for placement?* Yes No b. If “Yes” to 4a, does the applicant subcontract background checks to another party?* Yes No c. If “Yes” to 4b, does the contract have a hold harmless or indemnification clause in the applicant’s favor?* Yes No 5. What percentage of the applicant’s gross receipts are derived from placements with salaries greater than $250,000?%>strong>6. Percentage of placements by type: Chief Executive Officers:*%Architects/Engineers:*%Chief Financial Officers:*%Accountants/Bookkeepers/Payroll:*%Other Management & Executives:*%Financial Advisors:*%Office-based Professionals (non-legal, non-financial):*%Lawyers:*%Clerical:*%Doctors/Nurses:*%Data Processors:*%Nannies:*%Information Technology, Non-financial Office Applications:*%Police/Security:*%Information Technology, Security:*%Light Industrial:*%Information Technology, CAD/CAM:*%Information Technology, Military & Weapons:*%Information Technology, Other:*%Total 100%It is understood this supplement becomes part of application for business errors and omissions liability, and is utilized to develop information unique to the operations of the applicant. Signature*(Principal, Partner or Officer)Title:* Date:* MM slash DD slash YYYY Print Name:* (Please type full name in space provided)This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy, Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be amended by Endorsement or affected by State Laws.
