COVER-PRO
SM
APPLICATION
MANAGEMENT CONSULTANT SUPPLEMENT
1. Full name of the Applicant Firm:
2. Within the past five (5) years has the Applicant Firm:
a. consulted on mergers, acquisitions, capitalizations, dives
t
itures or liquidations
?
Yes
No
b. prepa
re
d, reviewe
d
or a
pproved architectural, engineering or construction maps,
plans, opinions, estima
tes, surveys, designs or specifications or otherwise been involved
with the design, construction, demolition or testing of any building or structure? <HV
1R Yes No
c. been involved in the management, purchase, sale or development of any real estate? Yes No
d. been involved in any financial consulting? Yes No
e. been involved in any environmental consulting? Yes No
3. Please indicate the percentage of the
Applicant’s gross annual revenue from the last fiscal period involving:
(A
) (B)
Executive search / Recruiting: % Feasibility studies: %
Human resource consulting: % Management audits: %
Education / Training: % Project management: %
Quality improvement / Quality control: % Management / Ownership
Business communication: %
succession planning: %
Administrative / Office services: %
TOTAL (A)
% TOTAL (B): %
(C) (D)
Strategic and long range planning: % New business start-ups: %
Financial information and planning: % Finance & Accounting services: %
Mergers & Acquisitions: % Research & development: %
Long-term projects: (One or more) % Marketing services: %
Downsizing / Rightsizing: % EDP / MIS services: %
TOTAL (C): % TOTAL (D): %
(A) % + (B) % + (C)
%+ (D) % = TOTAL MUST EQUAL 100 %
4. Does the Applicant provide any se
rvices other than those services listed in question 3 above? Yes No
If yes, please describe.
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companie
s Cover-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print) Title (Must be Principal, Partner or Officer)
__________________________________________
Signature Date
PI-PLSP-MCSUPP 08/10 Page 1 of 2
