2023 Data Freeze — Professional Liability Change Request Form (EXTERNAL)

1
Applicant's Name* This field is required.
First Name
Last Name
2
Applicant's Policy Number* This field is required.ex. VETPRO123456
3
Applicant's AVMA Member Number* This field is required.
4
Applicant is a(n):
Employee
Sole Proprietor
Partner
Shareholder of corporation
Other
5
Applicant's Mailing AddressPersonal (non-business) address preferred
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
6
Applicant's EmailPersonal (non-business) email
example@example.com
7
Applicant's Office Number
Area Code
Phone Number
8
Applicant's Mobile NumberPersonal (non-business) phone number
Area Code
Phone Number
9
Applicant's Fax Number
Area Code
Phone Number
10
How would the applicant like to receive future policy documents (including renewal)?
Email
Mail
11
Would the applicant like to opt in to receive Text/SMS messaging as an alternative method for policy updates?By opting in to Text/SMS, I agree to the Terms of Service & Privacy Policy (http://slkt.io/TxOw). 1 Msg/Month. Message & data rates may apply.
YESNO
12
How does the applicant classify their work by species type?The Trust classifies wildlife, zoo, and fur-bearing animals as small animal. Cervidae, poultry, and ratites are classified as food animals. Refer to avamplit.com/PL for additional details.
Predominately Equine (70-100% of professional activity is devoted to equine practice)
Food Animal or Mixed Practice (70-100% of professional activity is devoted to food animal practice OR any combination in which no one animal type is 70% or more)
Predominately Small Animal (70-89% of professional activity is devoted to small animal practice)
Small Animal Exclusive (90-100% of professional activity is devoted to small animal practice )
13
Does the applicant want to change their professional liability plan selection?Please only answer "Yes" if a change to your current plan is required.
YESNO
14
Select a Professional Liability plan limit.Limits below are listed as per occurrence / annual aggregate. Refer to avmaplit.com/PL for additional details.
Plan 1 ($100,000 / $300,000)
Plan 2 ($300,000 / $900,000)
Plan 3 ($1,000,000 / $3,000,000)
15
Select an Excess plan limit.You must have Professional Liability Plan 3 to qualify. Refer to avmaplit.com/VLD for additional details.
Plan 1 ($1,000,000 / $1,000,000)
Plan 2 ($2,000,000 / $2,000,000)
Plan 3 ($3,000,000 / $3,000,000)
Plan 4 ($4,000,000 / $4,000,000)
Plan 5 ($5,000,000 / $5,000,000)
Decline excess liability coverage
16
Does the applicant want to add/change/remove veterinary license defense coverage?Legal fees to defend your veterinary license are not covered under the Professional Liability plan limits. Veterinary License Defense coverage responds when you incur legal costs to defend your veterinary license if a complaint is filed with your state licensing agency (subject to policy terms, conditions, and exclusions). Refer to avmaplit.com/VLD for additional details.
YESNO
17
Has the applicant had a regulatory action taken against any license in the past three years?If yes, this endorsement is NOT available at this time. You are welcome to apply three years from the date of the regulatory action. A regulatory action means any formal warning, restriction, probation, fine, penalty, suspension, or revocation of any veterinary license. A dismissed complaint is not considered a regulatory action.
YESNO
18
Does the applicant have any pending actions against any license, or are they currently under investigation?If yes, this endorsement is NOT available at this time. You are welcome to apply three years from the date of the regulatory action. A regulatory action means any formal warning, restriction, probation, fine, penalty, suspension, or revocation of any veterinary license. A dismissed complaint is not considered a regulatory action.
YESNO
19
Select a Veterinary License Defense endorsement limit to add to the applicant's Professional Liability policy.
$25,000 limit ($104 annual premium)
$50,000 limit ($120 annual premium)
$100,000 limit ($135 annual premium)
Remove current coverage
20
Does the applicant want to add/change/remove Animal Bailee (professional extension) coverage? (Only available for practice owners.)If you hospitalize, board, or transport animals, you could be held accountable for many things that happen to them while in your care. This optional endorsement covers damage to animals in your care resulting from fire, wind, theft, escape, flood, vandalism, attack from other animals, and many other perils not related to treatment. Please only answer "Yes" if a change to your current plan is required.
YESNO
21
Office Location Address:
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
22
Select an Animal Bailee planListed values are per animal limit / transportation limit / per specified premises limit. Refer to avmaplit.com/bailee for option details.
Plan 1 ($2K / $6K / $25K)
Plan 2 ($4K / $12K / $50K)
Plan 3 ($6K / $18K / $75K)
Plan 4 ($8K / $24K / $100K)
Plan 5 ($10K / $30K / $130K)
Plan 6 ($16K / $48K / $200K)
Plan 7 ($20K / $60K / $250K)
Plan 8 ($25K / $75K / $315K)
Plan 9 ($50K / $150K / $625K)
Plan 10 ($100K / $300K / $1M)
Plan 11 ($250K / $750K / $1M)
Plan 12 ($500K / $1M / $1M)
Plan 13 ($1M / $1M / $3M)
23
Do additional locations need to be added/changed/removed?Animal Bailee coverage must be secured separately for each location. Please list any additional addresses or required changes. Skip this question if no change is required.
24
Select a date for these changes to begin:Must be a future date. At the earliest, policy changes go into effect a day after the date the change request was received.
Date
Year
Month
Day
25
By signing below, I confirm that all information is correct to the best of my knowledge. I understand that my coverage is effective on the date following receipt of this change request by the AVMA PLIT office.
Should be Empty: