PREどQUALIFICATION QUESTIONNAIRE

Tｴ;ﾐﾆ ┞ﾗ┌ aﾗヴ ┞ﾗ┌ヴ ｷﾐデWヴWゲデ ｷﾐ Hｷﾉﾉ Cﾗﾐゲデヴ┌Iデｷﾗﾐ Cﾗﾏヮ;ﾐ┞く Tﾗ HWデデWヴ ┌ﾐSWヴゲデ;ﾐS デｴW I;ヮ;HｷﾉｷデｷWゲ ﾗa ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ ;ﾐS HWゲデ ﾏ;デIｴ ┞ﾗ┌ ┘ｷデｴ a┌デ┌ヴW Hｷﾉﾉ Cﾗﾐゲデヴ┌Iデｷﾗﾐ ﾗヮヮﾗヴデ┌ﾐｷデｷWゲが ヮﾉW;ゲW IﾗﾏヮﾉWデW デｴW aﾗヴﾏ HWﾉﾗ┘ ;ﾐS Wﾏ;ｷﾉ ふaﾗヴﾏ ;ﾐS ;ﾐ┞ ;デデ;IｴﾏWﾐデゲぶ デﾗ ﾏ┗ｷIﾆWヴゲをｴｷﾉﾉIﾗﾐゲデヴ┌IデｷﾗﾐﾉﾉIくIﾗﾏく Yﾗ┌ヴ ;ヮヮヴﾗ┗;ﾉ ﾗヴ ヮヴWどケ┌;ﾉｷaｷI;デｷﾗﾐ Iﾗ┌ﾉS HW ヴWﾃWIデWS ﾗヴ SWﾉ;┞WS ｷa ;ﾉﾉ ｷﾐaﾗヴﾏ;デｷﾗﾐ ｷゲ ﾐﾗデ ヮヴﾗ┗ｷSWSく PﾉW;ゲW ﾐﾗデW デｴ;デ デｴｷゲ ｷゲ ; ヮヴWﾉｷﾏｷﾐ;ヴ┞ ヮヴWケ┌;ﾉｷaｷI;デｷﾗﾐ aﾗヴﾏ ;ﾐS ｷﾐIﾉ┌SWゲ ﾗﾐﾉ┞ ﾗ┌ヴ ﾏｷﾐｷﾏ┌ﾏ ヴWケ┌ｷヴWﾏWﾐデゲく ASSｷデｷﾗﾐ;ﾉ ｷﾐaﾗヴﾏ;デｷﾗﾐ ﾏ;┞ HW ヴWケ┌WゲデWS H┞ デｴW ﾃﾗH ﾗ┘ﾐWヴ ﾗヴ S┌W デﾗ デｴW デ┞ヮW ﾗa ┘ﾗヴﾆ デﾗ HW ヮWヴaﾗヴﾏWSく

SWIデｷﾗﾐ Iぎ B┌ゲｷﾐWゲゲ Iﾐaﾗヴﾏ;デｷﾗﾐ ヱく LWｪ;ﾉ Cﾗﾏヮ;ﾐ┞ N;ﾏW

ヲく Pｴ┞ゲｷI;ﾉ ASSヴWゲゲ Cｷデ┞ Sデ;デW Zｷヮ

ンく M;ｷﾉｷﾐｪ ASSヴWゲゲ Cｷデ┞ Sデ;デW Zｷヮ

ヴく OaaｷIW PｴﾗﾐW

ヵく WWHゲｷデW

ヶく Pヴｷﾏ;ヴ┞ Cﾗﾐデ;Iデ ふM┌ゲデ HW ;ﾐ OaaｷIWヴが M;ﾐ;ｪWヴ ﾗヴ PヴｷﾐIｷヮ;ﾉぶ

Αく Pヴｷﾏ;ヴ┞ Cﾗﾐデ;Iデ TｷデﾉW

Βく MﾗHｷﾉW ヮｴﾗﾐW

Γく Eﾏ;ｷﾉ

ゅPﾉW;ゲW ;デデ;Iｴ ; IﾗﾏヮﾉWデWS IRS WどΓ Fﾗヴﾏ ;ﾐS ゲ┌Hﾏｷデ ｷデ ┘ｷデｴ デｴｷゲ aﾗヴﾏく A Hﾉ;ﾐﾆ ｷゲ ｷﾐIﾉ┌SWS aﾗヴ ┞ﾗ┌ヴ ┌ゲWく SWIデｷﾗﾐ IIぎ Cﾗﾏヮ;ﾐ┞ Iﾐaﾗヴﾏ;デｷﾗﾐ ヱく SWﾉWIデ Iﾗﾏヮ;ﾐ┞ デ┞ヮW ふ;ﾉﾉ デｴ;デ ;ヮヮﾉ┞ぶ S┌HIﾗﾐデヴ;Iデﾗヴ S┌ヮヮﾉｷWヴ EﾐｪｷﾐWWヴ

AヴIｴｷデWIデ VWﾐSﾗヴ OデｴWヴふゲヮWIｷa┞ぶ

ヲく YW;ヴ Cﾗﾏヮ;ﾐ┞ Eゲデ;HﾉｷゲｴWS

ンく IﾐSｷI;デW ﾉ;ヴｪWゲデ Sﾗﾉﾉ;ヴ ┗ﾗﾉ┌ﾏW Iﾗﾐデヴ;Iデ IﾗﾏヮﾉWデWS デﾗ S;デWく

Aﾏﾗ┌ﾐデ ガ YW;ヴ

PヴﾗﾃWIデ N;ﾏW

DWゲIヴｷヮデｷﾗﾐ ﾗa SIﾗヮW ﾗa Wﾗヴﾆ

ヴく IﾐSｷI;デW ;ﾉﾉ ゲデ;デWゲ ｷﾐ ┘ｴｷIｴ ┞ﾗ┌ I;ﾐ ヮWヴaﾗヴﾏ ┘ﾗヴﾆ

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ヵく Ia ┞ﾗ┌ ｴﾗﾉS ; Iﾗﾐデヴ;Iデﾗヴげゲ ﾉｷIWﾐゲWが ヮﾉW;ゲW ﾉｷゲデ デｴW ゲデ;デWふゲぶが ﾉｷIWﾐゲW ﾐ┌ﾏHWヴふゲぶが W┝ヮｷヴ;デｷﾗﾐ S;デWふゲぶ ;ﾐS ﾗデｴWヴ ケ┌;ﾉｷaｷI;デｷﾗﾐゲく

LｷIWﾐゲW ﾐ┌ﾏHWヴ Sデ;デW E┝ヮｷヴ;デｷﾗﾐ D;デW OデｴWヴ

ヶく CｴWIﾆ ;ﾉﾉ H┌ｷﾉSｷﾐｪ デ┞ヮWゲ ﾗﾐ ┘ｴｷIｴ ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ ｴ;ゲ ┘ﾗヴﾆWSぎ

ES┌I;デｷﾗﾐっSIｴﾗﾗﾉゲ M;ﾐ┌a;Iデ┌ヴｷﾐｪ RWデ;ｷﾉ

CﾗﾐSﾗﾏｷﾐｷ┌ﾏゲ Fｷﾐ;ﾐIｷ;ﾉっB;ﾐﾆｷﾐｪ Mｷﾉｷデ;ヴ┞

SヮﾗヴデゲっAデｴﾉWデｷI F;IｷﾉｷデｷWゲ Cﾗﾐ┗Wﾐデｷﾗﾐ CWﾐデWヴゲっCﾗﾉｷゲW┌ﾏゲ Gﾗ┗WヴﾐﾏWﾐデっM┌ﾐｷIｷヮ;ﾉ M┌ゲW┌ﾏゲ Iﾐaヴ;ゲデヴ┌Iデ┌ヴW CﾗヴヴWIデｷﾗﾐ;ﾉ F;IｷﾉｷデｷWゲ HﾗデWﾉゲ OaaｷIW B┌ｷﾉSｷﾐｪゲ HW;ﾉデｴI;ヴWっHﾗゲヮｷデ;ﾉゲ IﾐS┌ゲデヴｷ;ﾉ RWゲｷSWﾐデｷ;ﾉ Uデｷﾉｷデ┞っPﾗ┘Wヴ

OデｴWヴぎ OデｴWヴぎ OデｴWヴぎ

Αく IﾐSｷI;デW デヴ;SWふゲぶ ｷﾐ ┘ｴｷIｴ ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ ゲヮWIｷ;ﾉｷ┣Wゲく CｷヴIﾉW ﾉｷゲデWS ｷデWﾏゲ ;ﾐSっﾗヴ ;SS ;ﾐ┞ IﾗﾏﾏWﾐデゲ デｴ;デ ｴWﾉヮ

ﾐ;ヴヴﾗ┘ ;ヴW;ゲ ｷﾐ ┘ｴｷIｴ ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ ｷゲ ヮヴﾗaｷIｷWﾐデく PﾉW;ゲW ｷﾐSｷI;デW ｷa ┞ﾗ┌ ;ヴW ; ゲ┌ヮヮﾉｷWヴ ﾗﾐﾉ┞く

EﾐｪｷﾐWWヴｷﾐｪが AヴIｴｷデWIデが S┌ヴ┗W┞ﾗヴが SヮWIｷ;ﾉ IﾐゲヮWIデｷﾗﾐゲが Pﾉ;ﾐ DWゲｷｪﾐWヴが WデIく

Dﾗﾗヴゲ わ WｷﾐSﾗ┘ゲ ふIﾗｷﾉｷﾐｪが ﾗ┗WヴｴW;S ゲWIデｷﾗﾐ;ﾉが ｴ;ヴS┘;ヴWが ｪﾉ;ゲゲが ゲｴﾗ┘Wヴ Sﾗﾗヴゲが WデIくぶ

F┌ヴﾐｷゲｴｷﾐｪゲ ふAヮヮﾉｷ;ﾐIWゲが HﾉｷﾐSゲが Iﾗ┌ﾐデWヴデﾗヮゲが I;HｷﾐWデゲが WデIくぶ

SｷデW Cﾗﾐゲデヴ┌Iデｷﾗﾐ ふIﾉW;ヴｷﾐｪが ｴ;┌ﾉｷﾐｪが ゲWSｷﾏWﾐデ わ Wヴﾗゲｷﾗﾐ Iﾗﾐデヴﾗﾉが SWﾏﾗﾉｷデｷﾗﾐが ヮｷﾉｷﾐｪゲが ヮ;┗ｷﾐｪが ヴWデ;ｷﾐｷﾐｪ ┘;ﾉﾉゲが WデIくぶ

FｷﾐｷゲｴWゲ ふSヴ┞┘;ﾉﾉが ヮ;ｷﾐデｷﾐｪが ACTが aﾉﾗﾗヴｷﾐｪが ┘;ﾉﾉヮ;ヮWヴが WデIくぶ

PヴWどWﾐｪｷﾐWWヴWS ﾏWデ;ﾉ H┌ｷﾉSｷﾐｪゲ

CﾗﾐIヴWデW ふI;ゲデどｷﾐどヮﾉ;IWが ヮヴWどI;ゲデが Sヴｷﾉﾉｷﾐｪが ゲﾉ;Hどﾗﾐどｪヴ;SWが ゲW;ﾉWヴが WデIくぶ

D┌ﾏヮゲデWヴゲが ヮﾗヴデ;HﾉW デﾗｷﾉWデゲが デWﾏヮﾗヴ;ヴ┞ aWﾐIｷﾐｪ わ H;ヴヴｷI;SWゲが デWﾏヮﾗヴ;ヴ┞ ゲデﾗヴ;ｪW デヴ;ｷﾉWヴゲ

Cﾗﾐ┗W┞ｷﾐｪ ゲ┞ゲデWﾏゲ ふWﾉW┗;デﾗヴゲが ｴﾗｷゲデゲが Iヴ;ﾐWゲが WデIくぶ

M;ゲﾗﾐヴ┞ ふHヴｷIﾆが ゲデ┌IIﾗが WデIくぶ Fヴ;ﾏｷﾐｪ ふ┘ﾗﾗS わ ﾏWデ;ﾉ ゲデ┌Sぶ FｷヴW ゲ┌ヮヮヴWゲゲｷﾗﾐ

MWデ;ﾉゲ ふゲデヴ┌Iデ┌ヴ;ﾉ ゲデWWﾉが ┘WﾉSｷﾐｪが ヴWH;ヴが ﾉｷﾐデWﾉゲが ヴ;ｷﾉｷﾐｪゲが WデIくぶ

Fﾉﾗﾗヴｷﾐｪ ふデｷﾉWが I;ヴヮWデが ┗ｷﾐ┞ﾉが ┘ﾗﾗSが ﾉ;ﾏｷﾐ;デWが WデIくぶ

Pﾉ┌ﾏHｷﾐｪ

WﾗﾗS わ Pﾉ;ゲデｷIゲ ふヴﾗ┌ｪｴ I;ヴヮWﾐデヴ┞ aヴ;ﾏｷﾐｪが デヴ┌ゲゲWゲが ┌ﾐSWヴﾉ;┞ﾏWﾐデが ゲｴWﾉ┗ｷﾐｪが デヴｷﾏ I;ヴヮWﾐデヴ┞が WデIくぶ

SヮWIｷ;ﾉデｷWゲ ふデﾗｷﾉWデ ;IIWゲゲﾗヴｷWゲが ヮ;ヴデｷデｷﾗﾐゲが ﾏ;ｷﾉ Hﾗ┝Wゲが ゲｷｪﾐゲが ;┘ﾐｷﾐｪゲが aｷヴWヮﾉ;IWが WデIくぶ

MWIｴ;ﾐｷI;ﾉ ふHVACぶ

TｴWヴﾏ;ﾉ わ Mﾗｷゲデ┌ヴW PヴﾗデWIデｷﾗﾐ ふゲｷSｷﾐｪが ヴﾗﾗaｷﾐｪが ｪ┌デデWヴゲが ｷﾐゲ┌ﾉ;デｷﾗﾐが WデIくぶ

Eケ┌ｷヮﾏWﾐデ ふCﾗﾏﾏWヴIｷ;ﾉ ;ﾐS ┌ﾐｷデ ﾆｷデIｴWﾐゲが ﾉ;┌ﾐSヴ┞が ｪ┞ﾏﾐ;ゲｷ┌ﾏが WデIくぶ

EﾉWIデヴｷI;ﾉ ふｷﾐゲデ;ﾉﾉ;デｷﾗﾐが aｷ┝デ┌ヴWゲが WデIくぶ

Cﾗﾏﾏ┌ﾐｷI;デｷﾗﾐゲ ふ;┌Sｷﾗど┗ｷSWﾗが WデIくぶ

EﾉWIデヴﾗﾐｷI S;aWデ┞ わ SWI┌ヴｷデ┞ ふ┗ｷSWﾗ ゲ┌ヴ┗Wｷﾉﾉ;ﾐIWが aｷヴW ;ﾐS ｪ;ゲ SWデWIデｷﾗﾐ ;ﾐS ;ﾉ;ヴﾏが WデIくぶ

C;ヴヮWﾐデWヴ

OデｴWヴぎ OデｴWヴぎ OデｴWヴぎ

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SWIデｷﾗﾐ IIIぎ Iﾐゲ┌ヴ;ﾐIW Iﾐaﾗヴﾏ;デｷﾗﾐ

PﾉW;ゲW ;デデ;Iｴ ; IﾗﾏヮﾉWデWS CWヴデｷaｷI;デW ﾗa Iﾐゲ┌ヴ;ﾐIW ふCOIぶ ┘ｷデｴ ┌ヮどデﾗどS;デW Iﾗ┗Wヴ;ｪWく A Hﾉ;ﾐﾆ aﾗヴﾏ ｷゲ ｷﾐIﾉ┌SWS aﾗヴ ┞ﾗ┌ヴ ┌ゲWく SWIデｷﾗﾐ IVぎ S;aWデ┞ Iﾐaﾗヴﾏ;デｷﾗﾐ

Dﾗ ┞ﾗ┌ ｴ;┗W ; ┘ヴｷデデWﾐ Cﾗﾏヮ;ﾐ┞ S;aWデ┞ PﾗﾉｷI┞ ;ﾐS Pヴﾗｪヴ;ﾏい YWゲ Nﾗ Ia ┞Wゲが ┘ｷﾉﾉ ┞ﾗ┌ ヮヴﾗ┗ｷSW ｷデ ｷa ヴWケ┌WゲデWSい YWゲ Nﾗ

SWIデｷﾗﾐ Vぎ LWｪ;ﾉ Iﾐaﾗヴﾏ;デｷﾗﾐ

ヱく H;ゲ ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ ﾗヴ ;ﾐ┞ ﾗa ｷデゲ ヮヴｷﾐIｷヮ;ﾉゲ W┗Wヴ ヮWデｷデｷﾗﾐWS aﾗヴ H;ﾐﾆヴ┌ヮデI┞が a;ｷﾉWS ｷﾐ H┌ゲｷﾐWゲゲが SWa;┌ﾉデWS ﾗヴ HWWﾐ デWヴﾏｷﾐ;デWS ﾗﾐ ; Iﾗﾐデヴ;Iデ ;┘;ヴSWS デﾗ ┞ﾗ┌い ぱぱ YWゲ ぱぱ Nﾗ Ia ┞Wゲが ヮﾉW;ゲW W┝ヮﾉ;ｷﾐぎ

ヲく H;┗W ;ﾐ┞ ﾗa デｴW ﾗ┘ﾐWヴゲが ﾗaaｷIWヴゲ ﾗヴ ﾏ;ﾃﾗヴ ゲデﾗIﾆｴﾗﾉSWヴゲ ﾗa ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ W┗Wﾐ HWWﾐ ｷﾐSｷIデWS ﾗヴ Iﾗﾐ┗ｷIデWS ﾗa ;ﾐ┞ aWﾉﾗﾐ┞ ﾗヴ ﾗデｴWヴ Iヴｷﾏｷﾐ;ﾉ IﾗﾐS┌Iデい ぱぱ YWゲ ぱぱ Nﾗ Ia ┞Wゲが ヮﾉW;ゲW W┝ヮﾉ;ｷﾐぎ

ンく H;ゲ ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞ W┗Wヴ HWWﾐ ヮヴWIﾉ┌SWS aヴﾗﾏ ヮ┌ヴゲ┌ｷﾐｪ ヮ┌HﾉｷI ┘ﾗヴﾆ ﾗヴ W┗Wヴ HWWﾐ aﾗ┌ﾐS デﾗ HW ; ﾐﾗﾐどヴWゲヮﾗﾐゲｷ┗W H┞ ; ヮ┌HﾉｷI ;ｪWﾐI┞い ぱぱ YWゲ ぱぱ Nﾗ Ia ┞Wゲが ヮﾉW;ゲW W┝ヮﾉ;ｷﾐぎ

SWIデｷﾗﾐ VIぎ RWaWヴWﾐIWゲ ;ﾐS ASSｷデｷﾗﾐ;ﾉ Iﾐaﾗヴﾏ;デｷﾗﾐ

Lｷゲデ デｴヴWW ヴWaWヴWﾐIWゲ aヴﾗﾏ ﾃﾗHゲ ┞ﾗ┌げ┗W ヮヴW┗ｷﾗ┌ゲﾉ┞ ┘ﾗヴﾆWS ﾗﾐく TｴWゲW ヴWaWヴWﾐIWゲ ﾏ;┞ HW Iﾗﾐデ;IデWSく

ヱく PヴﾗﾃWIデ N;ﾏW LﾗI;デｷﾗﾐ

Cﾗﾐデ;Iデ N;ﾏW PｴﾗﾐW N┌ﾏHWヴ

ヲく PヴﾗﾃWIデ N;ﾏW LﾗI;デｷﾗﾐ

Cﾗﾐデ;Iデ N;ﾏW PｴﾗﾐW N┌ﾏHWヴ

ンく PヴﾗﾃWIデ N;ﾏW LﾗI;デｷﾗﾐ

Cﾗﾐデ;Iデ N;ﾏW PｴﾗﾐW N┌ﾏHWヴ

PﾉW;ゲW ﾉｷゲデ ;ﾐ┞ ;SSｷデｷﾗﾐ;ﾉ ｷﾐaﾗヴﾏ;デｷﾗﾐ デｴ;デ ┞ﾗ┌ aWWﾉ ┘ｷﾉﾉ ｴWﾉヮ ┌ゲ SWデWヴﾏｷﾐW ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞げゲ ケ┌;ﾉｷaｷI;デｷﾗﾐゲ ;ﾐS W┝ヮWヴデｷゲWく Ia ;┗;ｷﾉ;HﾉWが ヮﾉW;ゲW ;デデ;Iｴ ;ﾐ ┌ヮS;デWS Iﾗヮ┞ ﾗa ┞ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞げゲ AIA Aンヰヵ DﾗI┌ﾏWﾐデく

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SWIデｷﾗﾐ VIIぎ ASSｷデｷﾗﾐ;ﾉ Cﾗﾐデ;Iデ Iﾐaﾗヴﾏ;デｷﾗﾐ

PﾉW;ゲW ﾉｷゲデ ;SSｷデｷﾗﾐ;ﾉ Iﾗﾐデ;Iデゲ aﾗヴ デｴW aﾗﾉﾉﾗ┘ｷﾐｪ ﾃﾗH a┌ﾐIデｷﾗﾐゲが ｷa ;ヮヮﾉｷI;HﾉWが ;ﾐS ;SS ﾗデｴWヴゲ ┞ﾗ┌ ﾏ;┞ ┘;ﾐデ ┌ゲ デﾗ ┌ゲWく

ヱく BｷﾉﾉｷﾐｪっP;┞ﾏWﾐデ Cﾗﾐデ;Iデ

Cﾗﾐデ;Iデ N;ﾏW TｷデﾉW

OaaｷIW ヮｴﾗﾐW MﾗHｷﾉW PｴﾗﾐW

Eﾏ;ｷﾉ

ヲく BｷS Cﾗﾐデ;Iデ

Cﾗﾐデ;Iデ N;ﾏW TｷデﾉW

OaaｷIW ヮｴﾗﾐW MﾗHｷﾉW PｴﾗﾐW

Eﾏ;ｷﾉ

ンく OデｴWヴ

Cﾗﾐデ;Iデ N;ﾏW TｷデﾉW

OaaｷIW ヮｴﾗﾐW MﾗHｷﾉW PｴﾗﾐW

Eﾏ;ｷﾉ

WW ｴ;┗W ;デデWﾏヮデWS デﾗ ;ﾐゲ┘Wヴ ;ﾉﾉ ケ┌Wゲデｷﾗﾐゲ ｷﾐ ; a┌ﾉﾉ ;ﾐS IﾗﾏヮﾉWデW ﾏ;ﾐﾐWヴ デﾗ ;ゲゲ┌ヴW デｴ;デ ﾗ┌ヴ ;ﾐゲ┘Wヴゲ ;ヴW ﾐﾗデ ｷﾐ ;ﾐ┞ ヴWゲヮWIデ ﾏｷゲﾉW;Sｷﾐｪ WｷデｴWヴ H┞ W┝ヮヴWゲゲｷﾐｪ ﾗ┌ヴゲWﾉ┗Wゲ ｷﾐ ; ﾏｷゲﾉW;Sｷﾐｪ ﾗヴ ;ﾏHｷｪ┌ﾗ┌ゲ ﾏ;ﾐﾐWヴ ﾗヴ ﾗﾏｷデデｷﾐｪ ｷﾐaﾗヴﾏ;デｷﾗﾐく WW ヴWIﾗｪﾐｷ┣W デｴ;デ Hｷﾉﾉ Cﾗﾐゲデヴ┌Iデｷﾗﾐ Cﾗﾏヮ;ﾐ┞ ┘ｷﾉﾉ HW ヴWﾉ┞ｷﾐｪ ﾗﾐ デｴW ;II┌ヴ;I┞ ﾗa デｴW ｷﾐaﾗヴﾏ;デｷﾗﾐ ;ﾐS ﾗ┌ヴ ヴWゲヮﾗﾐゲWゲ ｷﾐ デｴｷゲ ケ┌Wゲデｷﾗﾐﾐ;ｷヴW ｷﾐ SWIｷSｷﾐｪ ┘ｴWデｴWヴ デﾗ ヮWヴﾏｷデ ┌ゲ デﾗ HｷS ;ﾐS ｷﾐ ;┘;ヴSｷﾐｪ ┘ﾗヴﾆ デﾗ ﾗ┌ヴ Iﾗﾏヮ;ﾐ┞く Tｴｷゲ ゲWIデｷﾗﾐ ﾏ┌ゲデ HW ゲｷｪﾐWS H┞ ;ﾐ ﾗaaｷIWヴが ﾏ;ﾐ;ｪWヴが ﾗヴ ヮヴｷﾐIｷヮ;ﾉ ﾗa デｴW Iﾗﾏヮ;ﾐ┞く

Sｷｪﾐ;デ┌ヴW

PヴｷﾐデWS N;ﾏW

TｷデﾉW

D;デW

Aデデ;IｴﾏWﾐデゲぎ WどΓ COI

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:CONTACT

(A/C, No):FAX

E-MAILADDRESS:

PRODUCER

(A/C, No, Ext):PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to

the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the

certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES

BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

(Per accident)

(Ea accident)

$

$

N / A

SUBRWVD

ADDLINSR

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$

$

$

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS

AUTOSAUTOSNON-OWNED

HIRED AUTOS

SCHEDULEDALL OWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?(Mandatory in NH)

DESCRIPTION OF OPERATIONS belowIf yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

$

$

$

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

EROTH-

TORY LIMITSWC STATU-

LIMITS(MM/DD/YYYY)POLICY EXP

(MM/DD/YYYY)POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTRINSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

$

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCEDAMAGE TO RENTED

$PREMISES (Ea occurrence)

GENERAL LIABILITY

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICYPRO-JECT LOC

CERTIFICATE OF LIABILITY INSURANCEDATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

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CERTIFICATE HOLDER

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