Workers' Compensation Quick Form

Thank you for your interest in the PLIT-sponsored 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:
Including DBA names.

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* 2. Legal Structure:

Sole Proprietor

Partnership

Corporation

LLC

PLLC

Other (please specify)

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* 3. Practice Type:

Small Animal Exclusive

Predominantly Small Animal

Predominantly Large/Food Animal

Equine Exclusive

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* 4. Practice Owner's Name:

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* 5. Insurance Contact's Name:
If different from practice owner's.

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* 6. Telephone Number:

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* 7. Mailing Address

Address

City

State

Zip Code

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* 8. Physical Address
If different from practice owner's.

Address

City

State

Zip Code

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

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* 10. Years in Business:

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* 11. Estimated Total Assets ($):

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* 12. FEIN:
Federal Employer Identification Number

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* 13. Do you currently use a payroll service?

Yes

Unsure

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* 14. Expiration date of your current workers' compensation policy written through another agent or program.
If no policy exists, please enter the desired effective date of a new policy.

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* 15. Current workers' compensation policy carrier and premium.

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* 16. What is your experience modification factor?

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* 17. Please provide your employee count and payroll information for these three groups.
Enter zero (0) for groups that do not apply.

Animal Handlers:
Number of full-time employees

Animal Handlers:
Number of part-time employees

Animal Handlers:
Estimated gross annual payroll

Owners and Officers (to be included in coverage):
Number of full-time employees

Owners and Officers (to be included in coverage):
Number of part-time employees

Owners and Officers (to be included in coverage):
Estimated gross annual payroll

Clerical Staff (no animal contact):
Number of full-time employees

Clerical Staff (no animal contact):
Number of part-time employees

Clerical Staff (no animal contact):
Estimated gross annual payroll

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* 18. List the names of all owners and officers that you would like to INCLUDE in coverage:

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* 19. List the names of all owners and offices that you would like to EXCLUDE from coverage:

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* 20. Would you like to include coverage for the spouse of an owner or officer who is an employee of the practice?

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* 21. List all claims that occurred the past four years including date, approximate amount paid, and injury type:
Injury Type = animal bite/scratch, lifting sprain/strain, slip/trip/fall, other (please explain)

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* 22. Check all that apply regarding your current safety program:

Formal training for new hires

Employee handbook required to be read and signed by all employees

Routine safety meetings for new and current employees

Training on proper lifting techniques

Adequate safeguards on equipment/machinery

Positive management attitude towards safety

OSHA compliance

Exam Tables that raise and lower

Aggressive animal policy

Protective clothing for handling animals

Disciplinary Program when employee does not follow safety protocol

Return to work program

First aid kits readily available

None of the above

Question Title

* 1. Legal Business Name:Including DBA names.

Question Title

* 2. Legal Structure:

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* 3. Practice Type:

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* 4. Practice Owner's Name:

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* 5. Insurance Contact's Name:If different from practice owner's.

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* 6. Telephone Number:

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* 7. Mailing Address

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* 8. Physical AddressIf different from practice owner's.

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

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* 10. Years in Business:

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* 11. Estimated Total Assets ($):

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* 12. FEIN:Federal Employer Identification Number

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* 13. Do you currently use a payroll service?

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* 14. Expiration date of your current workers' compensation policy written through another agent or program.If no policy exists, please enter the desired effective date of a new policy.

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* 15. Current workers' compensation policy carrier and premium.

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* 16. What is your experience modification factor?

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* 17. Please provide your employee count and payroll information for these three groups.Enter zero (0) for groups that do not apply.

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* 18. List the names of all owners and officers that you would like to INCLUDE in coverage:

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* 19. List the names of all owners and offices that you would like to EXCLUDE from coverage:

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* 20. Would you like to include coverage for the spouse of an owner or officer who is an employee of the practice?

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* 21. List all claims that occurred the past four years including date, approximate amount paid, and injury type:Injury Type = animal bite/scratch, lifting sprain/strain, slip/trip/fall, other (please explain)

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* 22. Check all that apply regarding your current safety program:

* 1. Legal Business Name:
Including DBA names.

* 5. Insurance Contact's Name:
If different from practice owner's.

* 8. Physical Address
If different from practice owner's.

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

* 12. FEIN:
Federal Employer Identification Number

* 14. Expiration date of your current workers' compensation policy written through another agent or program.
If no policy exists, please enter the desired effective date of a new policy.

* 17. Please provide your employee count and payroll information for these three groups.
Enter zero (0) for groups that do not apply.

* 21. List all claims that occurred the past four years including date, approximate amount paid, and injury type:
Injury Type = animal bite/scratch, lifting sprain/strain, slip/trip/fall, other (please explain)