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AAHA: Employment Practices Liabilities 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.
Your name, company, practice address, email and phone number
(Required.)
Name
Practice Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
*
5.
How many years has the practice been in business?
(Required.)
*
6.
How many locations does your practice have?
(Required.)
*
7.
How many employees do you have?
(Required.)
Current
Full-time
Part-time
Volunteers
Independent contractors
Employee count one year ago
*
8.
Total Current Number of Employees with compensation (including bonuses):
(Required.)
Less than $50,000
$50,000 to $100,000
$101,000 to $250,000
Greater than $250,000
*
9.
Within the last 3 years, has the Applicant been the subject of or involved in any claim, written demand, notice, proceeding, litigation or investigation alleging a discriminatory practice, unlawful harassment or any other employment or labor related violations?
(Required.)
Yes
No
*
10.
How many employees, including veterinarians, have been involuntarily terminated in the past 12 months?
(Required.)
11.
None of the individuals to be insured under this coverage is responsible for or has knowledge of any wrongful act or fact, circumstance or situation which they have reason to believe might result in a future claim, except as follows (if None, so state):
*
12.
Have you distributed to employees written policies, guidelines or procedures addressing human resources issues?
(Required.)
Yes
No
13.
Are you interested in any of these other AAHA Business Insurance Program coverages?
Business Property & General Liability
Flood
Commercial Auto
Umbrella & Excess Liability
Workers' compensation
Directors & Officers Liability
Cyber Liability
