Thank you for your interest in the AVMA PLIT Program. Please answer the following questions and one of our insurance professionals will provide a free quotation.

* 1. Legal Business Name:

* 2. Practice Owner's Name:

* 3. Insurance Contact Name:

* 4. Mailing Address:

* 5. Physical Address:

* 6. Telephone Number:

* 7. Fax:

* 8. Private Email Address:

* 9. Practice Type:

* 10. Legal Structure:

* 11. Policy Type:

* 12. Waiting Period:

* 13. Current Policy:

* 14. Mortgagee(s) Loan Requirement: 

* 15. If yes, loan number:

* 16. Construction Date:

Date 
/
/

* 17. Building in the course of construction?

* 18. If yes, is building walled and roofed?

* 19. Building located on federal land?

* 20. Building Occupancy Type:

* 21. Number of Units:

* 22. Building Type:

* 23. Foundation:

* 24. Number of Floors:

* 25. Attached Garage

* 26. If yes, is garage properly vented?

* 27. Condo Form of Ownership?

* 28. Condo Description:

* 29. Machinery or equipment servicing the building located in the basement:

* 30. If yes:

* 31. Full replacement cost of building:

* 32. Building coverage amount (increments of $50,000 for PRP up to $500,000):

* 33. Excess flood application:

* 34. Building deductible amount:

* 35. Content Coverage Amount (increments of $50,000 for PRP up to $500,000):

* 36. Content Deductible Amount:

* 37. Location of Contents:

T