Veterinary Clinic Insurance Questionnaire

Veterinarian Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION
1. How long have you been in business?
2. Please describe your operations.
2a. Does your company operate under different company names?

YesNo
2b. What percent of total receipts is each named insured?
3. In what state(s) do you conduct business?
4. Number of employees: (Employees include: Sole Proprietors, Partners, Executive Officers, Seasonal Employees, Part-time, Full-time)

Rows Full-Time Part-Time

Number of Employees
5. What pre-employment screening is used?
6. Do you have volunteers sign a waiver? (Please provide a copy of the waiver.)

YesNo
7. Is any work sub-contracted?

YesNo
7a. If yes, what type of work is subcontracted out?
7b. What is total cost of subcontracted work?
7c. Do you obtain a certificate of insurance from the subcontractors?

YesNo
8. Do you have any losses in the last five years?

YesNo
8a. If yes, please provide date(s) and explain.

Rows	Full-Time	Part-Time
Number of Employees

Veterinarian Insurance Questionnaire