Please provide answers to the questions listed below.

Page1 / 3
 
Legal Business Name:
Including DBA names.

Question Title

* 1. Legal Business Name:
Including DBA names.

Practice Owner's Name:

Question Title

* 2. Practice Owner's Name:

Insurance Contact Name:
If different from practice owner.

Question Title

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

Phone Number:

Question Title

* 5. Phone Number:

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

Question Title

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

Web Address: 

Question Title

* 7. Web Address: 

How many years have you been in business?

Question Title

* 8. How many years have you been in business?

Approximate gross annual revenue:

Question Title

* 9. Approximate gross annual revenue:

Do you currently have business property and general liability coverage through the AVMA PLIT-sponsored Program?
Also referred to as a business owner’s policy, BOP, or package policy.

Question Title

* 10. Do you currently have business property and general liability coverage through the AVMA PLIT-sponsored Program?
Also referred to as a business owner’s policy, BOP, or package policy.

How much coverage would you like?

Question Title

* 11. How much coverage would you like?

T