Please provide answers to the questions listed below.

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* 1. Legal Business Name:
Including DBA names.

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* 2. Practice Owner's Name:

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

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* 4. In which state is your practice located?

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* 5. Phone Number:

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

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* 7. Web Address: 

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

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* 9. Approximate gross annual revenue:

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* 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.

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* 11. How much coverage would you like?

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