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.

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* 1. Legal Business Name:

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* 2. Practice Owner's Name:

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* 3. Insurance Contact Name:

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* 4. Mailing Address:

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* 5. Physical Address:

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* 6. Telephone Number:

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* 7. Fax:

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* 8. Private Email Address:

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* 9. Practice Type:

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* 10. Legal Structure:

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* 11. Policy Type:

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* 12. Waiting Period:

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* 13. Current Policy:

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* 14. Mortgagee(s) Loan Requirement: 

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* 15. If yes, loan number:

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* 16. Construction Date:

Date

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* 17. Building in the course of construction?

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

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* 19. Building located on federal land?

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* 20. Building Occupancy Type:

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* 21. Number of Units:

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* 22. Building Type:

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* 23. Foundation:

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* 24. Number of Floors:

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* 25. Attached Garage

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* 26. If yes, is garage properly vented?

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* 27. Condo Form of Ownership?

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* 28. Condo Description:

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

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* 30. If yes:

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* 31. Full replacement cost of building:

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

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* 33. Excess flood application:

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* 34. Building deductible amount:

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

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* 36. Content Deductible Amount:

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* 37. Location of Contents:

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