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Request a Quote: Homeowner's, Renter's and Auto Insurance
This exclusive member benefit is available to AVMA Trust members, their families, and their veterinary employees through the AVMA Trust.
27
Questions
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1
Full Name
*
This field is required.
Prefix
First Name
Last Name
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2
Date of birth
*
This field is required.
-
Date
Year
Month
Day
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3
Home address
*
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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
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4
Your spouse's full name
Prefix
First Name
Last Name
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5
Your spouse's date of birth
-
Date
Year
Month
Day
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6
What type of coverage are you looking to review?
*
This field is required.
Property (Homeowner's or Renter's)
Auto
Both Property (Homeowner's or Renter's) and Auto
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7
Do you own your home or rent?
*
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Own
Rent
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8
What is your style of home?
*
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Dwelling
Condo/Co-Op
Apartment
Other
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9
What year was your home built?
*
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10
What is your home's square footage?
*
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11
What is your home's foundation type?
*
This field is required.
Basement
Slab
Crawl space
Piers/Pile
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12
Have there been any claims on the property in the last 5 years?
*
This field is required.
YES
NO
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13
Please describe any recent claims:
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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14
Does the home have any mitigation features? Select all that apply:
*
This field is required.
Smoke Detectors
Fire Alarms
Burglar Alarms
Sprinkler System
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15
Is your veterinary business located on your home's premises?
*
This field is required.
YES
NO
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16
Do any animals live in your home?
*
This field is required.
YES
NO
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17
Please describe the animals that live your home
*
This field is required.
Animal type/breed
Number of animals
Animal type/breed
Number of animals
Animal type/breed
Number of animals
Animal type/breed
Number of animals
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18
Do you own or lease a vehicle(s)?
*
This field is required.
YES
NO
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19
Please list a vehicle you own or lease
*
This field is required.
Make (eg. Ford)
Model (eg. Focus)
Year
VIN
Please Select
Yes
No
Please Select
Please Select
Yes
No
Additional vehicles?
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20
Please list another vehicle you own or lease (2)
*
This field is required.
Make (eg. Ford)
Model (eg. Focus)
Year
VIN
Please Select
Yes
No
Please Select
Please Select
Yes
No
Additional vehicles?
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21
Please list another vehicle you own or lease (3)
*
This field is required.
Make (eg. Ford)
Model (eg. Focus)
Year
VIN
Please Select
Yes
No
Please Select
Please Select
Yes
No
Additional vehicles?
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22
Please list another vehicle you own or lease (4)
*
This field is required.
Make (eg. Ford)
Model (eg. Focus)
Year
VIN
Please Select
Yes
No
Please Select
Please Select
Yes
No
Additional vehicles?
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23
What is your driver's license number?
*
This field is required.
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24
If there is an additional driver in the home, please share their name.
First Name
Last Name
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25
If there is an additional driver in the home, please share their date of birth.
-
Date
Year
Month
Day
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26
If there is an additional driver in the home, please share their driver's license number.
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27
To compare this quote to your existing policy, please attach your current declarations page.
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28
How would you prefer to be contacted?
*
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Email
Phone
No Preference
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29
Email
*
This field is required.
example@example.com
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30
Cell phone number
*
This field is required.
Area Code
Phone Number
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31
When is the best time to call?
*
This field is required.
Please include days of the week and times of the day (with timezone)
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