AVMA PLIT Business Owner's Package (BOP) Quote Form

1
Your Name* This field is required.
First Name
Last Name
2
Your Email* This field is required.
example@example.com
3
Your Phone Number* This field is required.
Area Code
Phone Number
4
Your job title/role in the practice
5
When should we contact you?* This field is required.Please include preferred time of day (with timezone) and days of the week
6
What is the practice's name?* This field is required.
7
What is the practice's legal business name?* This field is required.Including DBA names
8
What is the practice's address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Who is the practice owner?* This field is required.
First Name
Last Name
10
What is the practice's legal structure?* This field is required.
Sole Proprietor
Partnership
Corporation
LLC
PLLC
Other
11
How is the practice classified by animal type?* This field is required.The Trust classifies wildlife, zoo, and fur-bearing animals as small animal. Cervidae, poultry, and ratites are classified as food animals.
Equine Exclusive (90% or more)
Small Animal Exclusive (90% or more)
Predominantly Small Animal (70% or more)
Predominantly Large/Food Animal (70% or more)
Mixed Practice (no dominant species or group)
12
How many years has the practice been in business?* This field is required.Enter 0, if total years in business is less than 1
13
What is the practice's estimated total revenue ($)?* This field is required.
$ USD
14
How many employees work at the practice?* This field is required.
15
What is the estimated total value of all building contents?* This field is required.Equipment, computers, medications, etc.
16
What is the estimated annual payroll ($) for all employees?* This field is required.
$ USD
17
Does the practice utilize or do any of the following?* This field is required.Please check all that apply
Store semen and/or embryos
Breed animals
Employ Mobile Practitioner(s)
Practice-owned vehicles
Practice employees use their personal vehicles for business purposes
Offer a 401(k) plan to employees
All doctors at the practice carry an individual professional liability policy through the PLIT-sponsored Program
None of the above
18
Does the practice currently have a package (property/general liability) insurance policy?* This field is required.
YESNO
19
When would you like a new package (property/general liability) policy to begin?* This field is required.
Date
Year
Month
Day
20
What is the expiration date of the practice's current package (property/general liability) policy?* This field is required.
Date
Year
Month
Day
21
Who is the practice's current package policy insurance carrier?* This field is required.
22
What is the annual premium for your current package policy?* This field is required.How much do you pay for this coverage each year?
$ USD
23
What is the physical address of the primary covered location (if different from the previously entered address)?Please note: buildings located more than 1,000 feet from the primary covered location must be listed separately
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
24
Does the practice own or lease this property?* This field is required.
Own
Lease
25
In the event of a total loss, how much would it cost to rebuild this property?* This field is required.This is the building's coverage "limit"
$ USD
26
Has the practice made any permanent additions or changes to the property?* This field is required.
YESNO
27
What is the dollar ($) value of those additions or changes?* This field is required.
$ USD
28
Are you interested in purchasing additional liability limits?* This field is required.(typically in the form of an umbrella policy)
YESNO
29
Does the practice own mobile equipment?* This field is required.
YESNO
30
What is the replacement dollar ($) value of your mobile equipment?* This field is required.In other words, how much would it cost to buy replacements for your mobile equipment if it were destroyed?
$ USD
31
Please select your preferred deductible amount for the practice's package policy:* This field is required.This is how much the practice would owe before the insurance carrier pays out on a covered claim.
$500
$1,000
$2,500
$5,000
32
What is the building's construction type?* This field is required.
Frame
Joisted Masonry
Non-combustible
Fire resistive
Modified fire resistive
Masonry non-combustible
Mobile home
Unknown/Unsure
Other
33
Which most accurately describes the practice's alarm system?* This field is required.
Central stationNo alarm
34
Does the building have a basement?* This field is required.
YESNO
35
Does the building have multiple, above-ground floors?* This field is required.ie. levels or stories
YESNO
36
How many above-ground floors?* This field is required.ie. levels or stories
37
What is the square footage of the building?* This field is required.
38
Does another business occupy the building?* This field is required.
YESNO
39
What percentage (%) of the building does the practice occupy?* This field is required.
40
In what year was the building constructed?* This field is required.
41
Please list the date of and describe the extent of any renovations to: wiring, heating, plumbing or roof.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
42
Do you require property coverage for additional locations/buildings?* This field is required.
YESNO
43
Please list all entities who have ownership in the practice's property* This field is required.
Huge
Large
Normal
Small
Ok
Ok
44
Please name loss payees, mortgagees and any additional insureds who should be listed on the policy* This field is required.
Huge
Large
Normal
Small
Ok
Ok
45
Please list all claims that have occurred in the past four (4) years* This field is required.Include date, description of incident and amount paid.
Huge
Large
Normal
Small
Ok
Ok
46
Check all that apply regarding your current safety program* This field is required.
New employees participate in an orientation program
Management endorses a no smoking policy
Management has posted emergency evacuation plan in a visible area of each unit
All buildings and parking areas are well lit and there is appropriate emergency lighting
Regular maintenance is performed on all electrical and plumbing within the building
Building has operable smoke detectors that are checked monthly
None of the above
47
Is the practice covered by any of these insurance policies through the PLIT?
Workers' compensation
Employment practices liability
Commercial auto
Flood
Builder's risk
Earthquake
None of the above
Unsure
Should be Empty: