• VETERINARY - INDIVIDUAL PROFESSIONAL LIABILITY

  • Butler Vet Insurance has partners with Pharmacists Mutual to provide comprehensive professional liability insurance policy for vets via their PM Vet Protect policy.

    Whether you've been in practice for decades or are just out of vet school. We work with experienced veterinary industry experts to provide professional liability coverage that helps protect your livelihood.

    You're not just getting great coverage. You're getting peace of mind, so you can spend less time worrying about potential lawsuits and more time providing excellent care for your animal patients.

  • ~ Priot to completing this form ~

    Please review the states we do business and are licensed to sell insurance.

    If we are not licensed in your state please contact us to provide you with a referal to one of our partners.

  • APPLICANT INFORMATION

  • Format: (000) 000-0000.
  • DVM Graduation Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • COVERAGE INFORMATION

  • Requested Coverage Effective Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Professional Liability Limits*
  • Waive Consent to Settle: Selecting “Yes” means you allow the insurance company to settle a professional liability claim when it believes settlement is appropriate without requiring your approval. Selecting “No” means you retain your contractual consent rights regarding settlement, subject to the terms and conditions of the policy.*
  • Coverage Type - Occurance or Claims Made
  • Prior Coverage Start Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Animal Bailee Coverage: Protects the practice when a client's animal is injured, dies, is lost, or is damaged while under the care, custody, or control of the practice. This coverage is separate from professional liability and addresses damage to the animal itself while in your care.*
  • Embryo/Semen Storage (must have Animal Bailee):*
  • Please Select Optional Coverages
  • Associate DVM / Practice Owner or Relief DVM?*
  • Are you an Owner or Partner at the Practice?*
  • Would you like coverage for the entire practice?*
  • Small Animal Treats 100% small animal; includes exotic companion mammals; amphibian; avian & reptile pets*
  • Mixed Practice Treats 70% or greater small animal, less than 30% large animal (including equine)*
  • Large Animal Treats 30% or greater large animal - Bovine Exclusive, Porcine Exclusive, Large Animal Exclusive, Mixed Practice (Predominantly Large Animal), Mixed Practice (General), Equine, Poultry, Ratites*
  • Equine Treats 70% or greater equine*

  • PRACTICE INFORMATION

  • Professional Status:*
  • Have you experienced any gaps in coverage in the past five years?*
  • Have you ever had professional liability insurance declined, cancelled, refused renewal or issued on special terms (e.g., premium surcharge or deductible)? - *Missouri applicants - do not answer this question*
  • Have you had your license or certification denied, suspended, revoked or voluntarily surrendered?*
  • Has any allegation, claim, investigation or lawsuit been brought against you within the past 5 years?*
  • Have you ever been convicted of a crime, other than minor traffic offenses?*

  • UNDERWRITING INFORMATION

  • Do you require documentation of consent to treat?*
  • Are you accredited by the AVMA or AAHA?*
  • Do you treat race horses or specialty show horses?*
  • Do you provide any services off premises?*
  • Do you provide volunteer services?*
  • Do you provide any tele-veterinary services?*
  • Do you have an established vet-client relationship PRIOR to the tele-veterinary visit?*
  • What category of patients do you see (Select all that apply)?*
  • Are you utilizing both audio and visual services?*
  • Types of Provided Appointments:*
  • Do you provide any 24-hour emergency services?*
  • Do you provide boarding services?*
  • If yes for boarding, do you require proof of vaccinations for the animals you board?*
  • If yes for boarding, are all cages/pens/runs cleaned and disinfected after each animal visit?*
  • Do you require proof of vaccinations for the animals you board?*
  • If yes, do you have an established vet-client relationship PRIOR to the tele-veterinary visit?*
  • If no, do you have a process to establish that relationship?*
  • Are all cages/pens/runs cleaned and disinfected after each animal visit?*
  • Do you dispense prescriptions?*
  • If yes, are medications labeled with the drug dispensed and instructions for use?*
  • Do you dispense controlled substances?*
  • If yes, are controlled substances kept in a locked location?*
  • Do you have an internal diversion prevention policy?*
  • Do you monitor overuse by patients or owner?*
  • Do you compound medications for home use?*
  • Do you provide holistic or alternative services?*
  • Have you obtained appropriate certification to offer your services?*
  • Is the majority of your work performed in a research institution or for research purposes?*

  • AUTHORIZATION & SIGNATURE

  • Due to the level of potential risk to Pharmacists Mutual Insurance Group, it is important that we be able to make reasonable inquiries about operations and control processes to accurately and fairly underwrite your coverage. Any information collected in this questionnaire, in response to our follow-up questions, will be treated as confidential and used strictly for underwriting purposes.
  • By signing below, I agree that all the information provided is true, correct and complete to the best of my knowledge. I also agree to contact my agent if there are any changes to the information provided during the policy year.
  • Date:*
     / /
    2 digit month, 2 digit day, 4 digit year

  • A person who knowingly submits false information on the questionnaire with an intent to defraud or helps to commit a fraud against the insurer may be guilty of a crime and may be subject to criminal and civil penalties.

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