AVMA PLIT Business Owner's Package Quote Request

Please provide answers to the questions listed below.

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Question Title

* 1. Please tell us about yourself.

First Name

Last Name

Job Title

Email Address

Phone Number

Best Day/Tine to Contact

Question Title

* 2. Please tell us about your practice.

Owner's Name

Legal Business Name (including DBA names)

Practice Name

Mailing Street Address

City

State

Zip Code

Question Title

* 3. Legal Structure

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* 4. Practice Type

Question Title

* 5. Years in Business

Question Title

* 6. Expiration date of your current package (property/general liability) policy written through another agent or program.
*If no policy exists, please enter the desired effective date of a new policy.

Date / Time

Date

Time

AM/PM

Question Title

* 7. Current package (property/general liability) insurance carrier and annual premium.

Question Title

* 8. Practice Size

Estimated Total Assets

Estimated Annual Revenue

Employee Count: Animal Handlers

Estimated Annual Payroll: Animal Handlers

Employee Count: Clerical Staff

Estimated Annual Payroll: Clerical Staff

Question Title

* 9. Are you interested in purchasing additional liability limits in the form of an umbrella policy?

Yes

Question Title

* 10. Liability Exposures
Please check all that apply to your practice.

Mobile Practitioner

Practice offers a 401(k) plan to employees

Breed animals

Store semen and/or embryos

Practice owns vehicles

Practice employees use their personal vehicles for business purposes

All doctors at the practice carry an individual professional liability policy through the PLIT-sponsored Program

None of the above

Question Title

* 1. Please tell us about yourself.

Question Title

* 2. Please tell us about your practice.

Question Title

* 3. Legal Structure

Question Title

* 4. Practice Type

Question Title

* 5. Years in Business

Question Title

* 6. Expiration date of your current package (property/general liability) policy written through another agent or program.*If no policy exists, please enter the desired effective date of a new policy.

Question Title

* 7. Current package (property/general liability) insurance carrier and annual premium.

Question Title

* 8. Practice Size

Question Title

* 9. Are you interested in purchasing additional liability limits in the form of an umbrella policy?

Question Title

* 10. Liability ExposuresPlease check all that apply to your practice.

* 6. Expiration date of your current package (property/general liability) policy written through another agent or program.
*If no policy exists, please enter the desired effective date of a new policy.

* 10. Liability Exposures
Please check all that apply to your practice.