Birtwhistle & Livingston: Staff Coverage Form

Name of Applicant
Mailing Address
Contact Person
Phone #	Fax #
E-mail Address


List all of staff including members, partners and shareholders.

Name		License Number
Name of Current Insurer		Current Policy #
Specialty or Position		Average # of hours per week
Employee? Yes No	Date of Hire	Status? Independent Contractor

Name		License Number
Name of Current Insurer		Current Policy #
Specialty or Position		Average # of hours per week
Employee? Yes No	Date of Hire	Status? Independent Contractor

Name		License Number
Name of Current Insurer		Current Policy #
Specialty or Position		Average # of hours per week
Employee? Yes No	Date of Hire	Status? Independent Contractor

Name		License Number
Name of Current Insurer		Current Policy #
Specialty or Position		Average # of hours per week
Employee? Yes No	Date of Hire	Status? Independent Contractor

Name		License Number
Name of Current Insurer		Current Policy #
Specialty or Position		Average # of hours per week
Employee? Yes No	Date of Hire	Status? Independent Contractor

Name		License Number
Name of Current Insurer		Current Policy #
Specialty or Position		Average # of hours per week
Employee? Yes No	Date of Hire	Status? Independent Contractor