Legal Business Name:
Including DBA names.

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* 1. Legal Business Name:
Including DBA names.

Legal Structure 

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* 2. Legal Structure 

Practice Type

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* 3. Practice Type

Practice Owner's Name:

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* 4. Practice Owner's Name:

Insurance Contact Name:
If different from practice owner.

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* 5. Insurance Contact Name:
If different from practice owner.

Mailing Address:

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* 6. Mailing Address:

Physical Address

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* 7. Physical Address

Telephone Number:

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* 8. Telephone Number:

Email Address:
For security reasons, please provide a private email address not shared by multiple employees.

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* 9. Email Address:
For security reasons, please provide a private email address not shared by multiple employees.

Years in Business:

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* 10. Years in Business:

Number of Locations:

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* 11. Number of Locations:

Estimated total assets ($):

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* 12. Estimated total assets ($):

Employee Count:

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* 13. Employee Count:

Total Current Number of Employees with compensation (including bonuses) in the following categories:

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* 14. Total Current Number of Employees with compensation (including bonuses) in the following categories:

Number of Employees for annual income: 

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* 15. Number of Employees for annual income: 

How many Employees, including Veterinarians, have been involuntarily terminated in the past 12 months? 

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* 16. How many Employees, including Veterinarians, have been involuntarily terminated in the past 12 months? 

For each of the most recent years, how many Employees have voluntarily terminated?

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* 17. For each of the most recent years, how many Employees have voluntarily terminated?

Expiration date of your current employment practices liability policy written through another agent or program.
If no policy exists, please enter the desired effective date of a new policy.

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* 18. Expiration date of your current employment practices liability policy written through another agent or program.
If no policy exists, please enter the desired effective date of a new policy.

Date
Have you completed any of the following in the past eighteen (18) months? Are you in the process or do you plan to complete any of the following during the next twelve (12) months?

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* 19. Have you completed any of the following in the past eighteen (18) months? Are you in the process or do you plan to complete any of the following during the next twelve (12) months?

  True False
Our practice is not contemplating any layoffs, staff reductions, or facility closings that will affect more than 25% of the workforce.
Our practice has written guidelines or procedures addressing discrimination, sexual harassment, and employee complaints that are available to our employees.
Our practice is not a subsidiary or U.S. division of a foreign parent company.
During the past three (3) years, our practice has had fewer than three (3) EPL incidents and the total amount paid or reserved on all litigation was less than $50,000.
If you answered false to any of the questions above, please provide a brief explanation.

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* 20. If you answered false to any of the questions above, please provide a brief explanation.

T