2023 Data Freeze — Professional Liability Application (EXTERNAL)

1
Applicant's Name* This field is required.
First Name
Last Name
2
Applicant is a(n):* This field is required.
Employee
Sole Proprietor
Partner
Shareholder of corporation
Other
3
Applicant's Credentials* This field is required.
DVM
VMD
Other
4
Applicant's AVMA Member Number* This field is required.Active AVMA membership is required to initiate coverage
5
Applicant's Mailing Address* This field is required.Personal (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 Email* This field is required.Personal (non-business) email
example@example.com
7
Applicant's Office Number* This field is required.
Area Code
Phone Number
8
How would the applicant like to receive future policy documents (including renewal notices)?* This field is required.
Email
Mail
9
Would the applicant like to opt in to receive Text/SMS messaging as an alternative method for policy updates?* This field is required.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
10
Is the applicant licensed in their state of principal practice or otherwise legally practicing?* This field is required.
YESNO
11
If the applicant is neither licensed, nor legally practicing, please explain:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
How does the applicant classify their work by species 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. Refer to avmaplit.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
Select a Professional Liability primary plan limit* This field is required.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)
14
Select an Excess plan limit* This field is required.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
15
Is the applicant interested in Veterinary License Defense coverage?* This field is required.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
16
Has the applicant had a regulatory action taken against any license in the past three years?* This field is required.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
17
Does the applicant have any pending actions against any license, or are they currently under investigation?* This field is required.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
Select a Veterinary License Defense endorsement to add to the applicant's Professional Liability policy.* This field is required.
$25,000 limit ($104 annual premium)
$50,000 limit ($120 annual premium)
$100,000 limit ($135 annual premium)
19
Is the applicant a practice owner?* This field is required.
YESNO
20
Is the applicant interested in adding Animal Bailee (professional extension) coverage?* This field is required.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.
YESNO
21
Office Location 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
22
Select an Animal Bailee plan* This field is required.Listed 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
Does the applicant want to add Animal Bailee coverage for any additional locations?Animal Bailee coverage must be secured separately for each location. Please provide addresses for all locations for which coverage is needed.
24
Is the applicant interested in embryo/semen coverage?* This field is required.Coverage for storage of embryos and semen is not provided by the Professional Liability, Excess Limits, or Animal Bailee coverages. An AVMA PLIT representative will contact you for further details to secure this coverage.
YESNO
25
Select a date for the Professional Liability policy (and any selected endorsements) to begin.* This field is required.Must be a future date. At the earliest, policies begin a day after the date the application was received.
Date
Month
Day
Year
Should be Empty: