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AAHA: Workers' Compensation Quote Form
Please provide answers to the questions below.
*
1.
Legal Business Name
Including DBA names
(Required.)
*
2.
What is your practice's legal structure?
(Required.)
Sole proprietor
Corporation
Partnership
LLC
PLLC
Other (please specify)
*
3.
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)
*
4.
Practice owner's name?
(Required.)
*
5.
Insurance contact's name?
(Required.)
*
6.
Practice address, email and phone number
(Required.)
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
7.
Mailing Address
If different from the practice address
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
*
8.
How many years has the practice been in business?
(Required.)
*
9.
Federal Employer Identification Number (FEIN)
(Required.)
*
10.
Do you currently use a payroll service?
(Required.)
Yes
No
*
11.
Expiration date of your current workers' compensation policy written through another agent or program. If no policy exists, please enter the desired effective date of a new policy.
(Required.)
12.
What is your current workers' compensation policy carrier and annual premium?
Skip if not applicable
13.
What is your experience modification factor?
Skip if not applicable
*
14.
Please provide the employee count and payroll information for animal handlers in your practice.
Enter zero (0) for groups that do not apply
(Required.)
Animal Handlers: Number of full-time employees
Animal Handlers: Number of part-time employees
Animal Handlers: Estimated gross annual payroll
*
15.
Please provide the employee count and payroll information for clerical staff in your practice.
Enter zero (0) for groups that do not apply
(Required.)
Clerical Staff (no animal contact): Number of full-time employees
Clerical Staff (no animal contact): Number of part-time employees
Clerical Staff (no animal contact): Estimated gross annual payroll
16.
List the names of all owners and officers that you would like to INCLUDE in coverage:
17.
List the names of all owners and officers that you would like to EXCLUDE in coverage:
18.
Would you like to include coverage for the spouse of an owner or officer who is an employee of the practice?
*
19.
List all workers' compensation claims that occurred the past four years including date, approximate amount paid, and injury type:
Workers' compensation Injuries typically include (but are not limited to): animal bite/scratch, lifting sprain/strain or slip/trip/fall. Please elaborate on any other claims.
(Required.)
*
20.
Check all that apply regarding your current safety program:
(Required.)
Formal training for new hires
Employee handbook required to be read and signed by all employees
Routine safety meetings for new and current employees
Training on proper lifting techniques
Adequate safeguards on equipment/machinery
Positive management attitude towards safety
OSHA compliance
Exam Tables that raise and lower
Aggressive animal policy
Protective clothing for handling animals
Disciplinary Program when employee does not follow safety protocol
Return to work program
First aid kits readily available
None of the above
21.
Are you interested in any of these other AAHA Business Insurance Program coverages?
Business Property & General Liability
Flood
Commercial Auto
Umbrella & Excess Liability
Employment Practices Liability (EPL)
Directors & Officers Liability
Cyber Liability
