VETERINARY PROFESSIONAL LIABILITY REQUEST

  • 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.

  • APPLICANT INFORMATION

  • Format: (000) 000-0000.

  • COVERAGE INFORMATION

  • Requested Coverage Effective Date
     / /
  • Professional Liability Limits*
  • Coverage Type*
  • Prior Coverage Start Date*
     / /
  • Animal bailee:*
  • Embryo/Semen Storage (must have Animal Bailee):*

  • PRACTICE INFORMATION

  • Professional Status:*
  • 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*

  • UNDERWRITING INFORMATION

  • 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?*
  • 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?*
  • 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?*
  • 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 require documentation of consent to treat?*
  • Are you accredited by the AVMA or AAHA?*

  • COVERAGE HISTORY

  • 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*
  • Has any allegation, claim, investigation or lawsuit been brought against you within the past 5 years?*
  • Have you had your license or certification denied, suspended, revoked or voluntarily surrendered?*
  • Have you ever been convicted of a crime, other than minor traffic offenses?*

  • 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:*
     / /

  • 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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