PI-PLSP-TRANSUPP (04/10) Page 1 of 3
COVER-PRO
SM
APPLICATION
TRANSLATOR, INTERPRETER SUPPLEMENT
1. Full name of the Applicant Firm:
2. What percentage of the Applicant’s gross annual revenues are derived from:
Translation services: %
Interpreter services: %
How many years has the Applicant been translating / interpreting: years
3. What types of translation/interpretation services does the Applicant perform?
Judiciary interpretation/translation
Medical interpretation/translation
Sign language translation
Conference interpretation
Guide or escort interpretation
Literary translation
Localization translation
General business interpretation/translation
Contract interpretation/translation
Architecture or Engineering interpretation/translation
Financial interpretation/translation
Education interpretation/translation
Entertainment interpretation/translation
Other (specify):
4. Does the Applicant perform simultaneous interpretation? Yes No
If yes, does the Applicant work with a partner?
Yes No
If yes, what experience does the Applicant have on the subject requiring
interpretation?
5. Please list all job specific training programs or job specific exams successfully
completed.
6. Please list any federal, state or municipal court certifications as well as any association
certifications/credentials the Applicant currently holds.
7. Is the Applicant a member of any national associations? Yes No
If yes, provide a list of all memberships.
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PI-PLSP-TRANSUPP (04/10) Page 2 of 3
8. How many languages is the Applicant fluent?
List all languages in which the Applicant interprets/translates:
9. Please indicate the types of materials that are being translated / interpreted by the
Applicant.
10. Does the Applicant perform any proof reading and/or editorial services? Yes No
If yes, please explain.
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companies Cover-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print/Type) Title
(MUST BE SIGNED BY A PRINCIPAL, PARTNER OR OFFICER)
_______________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application,
including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other
insured persons.
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
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PI-PLSP-TRANSUPP (04/10) Page 3 of 3
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature
Date
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