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:

Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
How did you hear about us?

Other
GENERAL INFORMATION
1. How long have you been in business?
2. Please describe your operations.
2a. Does your company operate under different company names?
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.)
7. Is any work sub-contracted?
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?
8. Do you have any losses in the last five years?
8a. If yes, please provide date(s) and explain.

Veterinarian Insurance Questionnaire