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AAHA Business Owners Package (BOP) Quote Form
Please provide answers to the questions below.
*
1.
Your Name:
(Required.)
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2.
Email Address:
(Required.)
*
3.
Telephone Number:
(Required.)
4.
What is your job title/role at the practice?
*
5.
When should we contact you? Please include preferred time of day, your timezone, and the days of the week which work best.
(Required.)
*
6.
What is the name of your practice?
(Required.)
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7.
What your practice's legal business name?
Including DBA names.
(Required.)
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8.
What is your practice's address?
(Required.)
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
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9.
Who is the practice owner?
(Required.)
Name
*
10.
What is the practice's legal structure?
(Required.)
Sole Proprietor
Corporation
Partnership
LLC
PLLC
Other (please specify)
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11.
How is the practice classified by animal type?
The Trust classifies wildlife, zoo, and fur-bearing animals as small animal. Cervidae, poultry, and ratites are classified as food animals
(Required.)
Equine Exclusive (90% or more)
Small Animal Exclusive (90% or more)
Predominately Small Animal (70% or more)
Predominately Large/Food Animal (70% or more)
Mixed practice (no dominant species or group)
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12.
How many years has the practice been in business?
(Required.)
*
13.
What is the practice's estimated total revenue($)?
(Required.)
*
14.
How many employees work at the practice?
(Required.)
*
15.
What is the estimated total value of all building contents?
Computer, medications, equipment, etc.
(Required.)
*
16.
What is the estimated annual payroll ($) for all employees?
(Required.)
*
17.
Does the practice utilize any of the following?
(Required.)
Store semen and/or embryos
Breed animals
Employ mobile practitioner(s)
Practice-owned vehicles
Practice employees use their personal vehicles for business purposes
Offer a 401(k) plan to employees
All doctors at the practice carry an individual professional liability policy through the PLIT-sponsored Program
None of the above
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18.
Does the practice currently have a package (property/general liability) insurance policy?
(Required.)
Yes
No
19.
Who is the practice's current package policy carrier, the policies expiration date and the current premium?
Name of Carrier
Expiration Date
Current premium?
*
20.
When would you like a new package (property/general liability) policy to begin?
(Required.)
Please list the ideal date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
21.
What is the physical address of the primary covered location (if different from the previously entered address)?
Please note: buildings located more than 1,000 feet from the primary covered location must be listed separately
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
*
22.
Does the practice own or lease this property?
(Required.)
Own
Lease
*
23.
In the event of a total loss, how much would it cost to rebuild this property?
(Required.)
*
24.
Has the practice made any permanent additions or changes to the property?
(Required.)
Yes
No
25.
What is the dollar ($) value of those additions or changes?
*
26.
Are you interested in purchasing additional liability limits?
typically in the form of an umbrella policy
(Required.)
Yes
No
*
27.
Does your practice own mobile equipment?
(Required.)
Yes
No
28.
What is the replacement dollar ($) value of your mobile equipment?
In other words, how much would it cost to buy replacements for your mobile equipment if it were destroyed?
*
29.
Please select your preferred deductible amount for the practice's package policy
This is how much the practice would owe before the insurance carrier pays out on a covered claim
(Required.)
$500
$1,000
$2,500
$5,000
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30.
What is the building's construction type?
(Required.)
Frame
Non-combustible
Modified fire resistive
Mobile home
Jointed masonry
Fire resistive
Masonry non-combustible
Unknown/unsure
Other (please specify)
*
31.
Which most accurately describes the practice's alarm system?
(Required.)
Central station
No alarm
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32.
Does the building have a basement?
(Required.)
Yes
No
*
33.
Does the building have multiple, above-ground floors?
ie. levels or stories
(Required.)
Yes
No
34.
How many above-ground floors?
*
35.
What is the square footage of the building?
(Required.)
*
36.
Does another business occupy the building?
(Required.)
Yes
No
37.
What percentage (%) of the building does the practice occupy?
*
38.
In what year was the building constructed?
(Required.)
*
39.
Please list the date of and describe the extent of any renovations to: wiring, heating, plumbing or roof.
(Required.)
*
40.
Do you require property coverage for additional locations/buildings?
(Required.)
Yes
No
*
41.
Please list all entities who have ownership in the practice's property.
(Required.)
*
42.
Please name loss payees, mortgagees and any additional insureds who should be listed on the policy
(Required.)
*
43.
Please list all claims that have occurred in the past four (4) years.
Include date, description of incident and amount paid
(Required.)
*
44.
Check all that apply regarding your current safety program
(Required.)
New employees participate in an orientation program
Management endorses a no smoking policy
Management has posted emergency evacuation plan in a visible area of each unit
All buildings and parking areas are well lit and there is appropriate emergency lighting
Regular maintenance is performed on all electrical and plumbing within the building
Building has operable smoke detectors that are checked monthly
None of the above
45.
Are you interested in any of these other AAHA business insurance program products?
Flood
Commercial Auto
Umbrella & Excess Liability
Employment Practices Liability (EPL)
Directors & Officers Liability
Cyber Liability
Workers' Compensation
Current Progress,
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