AAHA: Workers' Compensation Quote Form

Please provide answers to the questions below.

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* 1. Legal Business Name
Including DBA names

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* 2. What is your practice's legal structure?

Sole proprietor

Corporation

Partnership

LLC

PLLC

Other (please specify)

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* 3. How is the practice classified by animal type?
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)

Predominately Small Animal (70% or more)

Predominately Large/Food Animal (70% or more)

Mixed practice (no dominant species or group)

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* 4. Practice owner's name?

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* 5. Insurance contact's name?

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* 6. Practice address, email and phone number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 7. Mailing Address
If different from the practice address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 8. How many years has the practice been in business?

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* 9. Federal Employer Identification Number (FEIN)

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* 10. Do you currently use a payroll service?

Yes

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* 11. Expiration date of your current workers' compensation policy written through another agent or program. If no policy exists, please enter the desired effective date of a new policy.

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* 12. What is your current workers' compensation policy carrier and annual premium?
Skip if not applicable

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* 13. What is your experience modification factor?
Skip if not applicable

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* 14. Please provide the employee count and payroll information for animal handlers in your practice.
Enter zero (0) for groups that do not apply

Animal Handlers: Number of full-time employees

Animal Handlers: Number of part-time employees

Animal Handlers: Estimated gross annual payroll

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* 15. Please provide the employee count and payroll information for clerical staff in your practice.
Enter zero (0) for groups that do not apply

Clerical Staff (no animal contact): Number of full-time employees

Clerical Staff (no animal contact): Number of part-time employees

Clerical Staff (no animal contact): Estimated gross annual payroll

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* 16. List the names of all owners and officers that you would like to INCLUDE in coverage:

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* 17. List the names of all owners and officers that you would like to EXCLUDE in coverage:

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* 18. Would you like to include coverage for the spouse of an owner or officer who is an employee of the practice?

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* 19. List all workers' compensation claims that occurred the past four years including date, approximate amount paid, and injury type:
Workers' compensation Injuries typically include (but are not limited to): animal bite/scratch, lifting sprain/strain or slip/trip/fall. Please elaborate on any other claims.

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* 20. Check all that apply regarding your current safety program:

Formal training for new hires

Employee handbook required to be read and signed by all employees

Routine safety meetings for new and current employees

Training on proper lifting techniques

Adequate safeguards on equipment/machinery

Positive management attitude towards safety

OSHA compliance

Exam Tables that raise and lower

Aggressive animal policy

Protective clothing for handling animals

Disciplinary Program when employee does not follow safety protocol

Return to work program

First aid kits readily available

None of the above

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* 21. Are you interested in any of these other AAHA Business Insurance Program coverages?

Business Property & General Liability

Flood

Commercial Auto

Umbrella & Excess Liability

Employment Practices Liability (EPL)

Directors & Officers Liability

Cyber Liability

Question Title

* 1. Legal Business Name Including DBA names

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* 2. What is your practice's legal structure?

Question Title

* 3. How is the practice classified by animal type? The Trust classifies wildlife, zoo, and fur-bearing animals as small animal. Cervidae, poultry, and ratites are classified as food animals

Question Title

* 4. Practice owner's name?

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* 5. Insurance contact's name?

Question Title

* 6. Practice address, email and phone number

Question Title

* 7. Mailing Address If different from the practice address

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* 8. How many years has the practice been in business?

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* 9. Federal Employer Identification Number (FEIN)

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* 10. Do you currently use a payroll service?

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* 11. Expiration date of your current workers' compensation policy written through another agent or program. If no policy exists, please enter the desired effective date of a new policy.

Question Title

* 12. What is your current workers' compensation policy carrier and annual premium? Skip if not applicable

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* 13. What is your experience modification factor? Skip if not applicable

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* 14. Please provide the employee count and payroll information for animal handlers in your practice. Enter zero (0) for groups that do not apply

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* 15. Please provide the employee count and payroll information for clerical staff in your practice. Enter zero (0) for groups that do not apply

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* 16. List the names of all owners and officers that you would like to INCLUDE in coverage:

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* 17. List the names of all owners and officers that you would like to EXCLUDE in coverage:

Question Title

* 18. Would you like to include coverage for the spouse of an owner or officer who is an employee of the practice?

Question Title

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* 20. Check all that apply regarding your current safety program:

Question Title

* 21. Are you interested in any of these other AAHA Business Insurance Program coverages?

* 1. Legal Business Name
Including DBA names

* 3. How is the practice classified by animal type?
The Trust classifies wildlife, zoo, and fur-bearing animals as small animal. Cervidae, poultry, and ratites are classified as food animals

* 7. Mailing Address
If different from the practice address

* 12. What is your current workers' compensation policy carrier and annual premium?
Skip if not applicable

* 13. What is your experience modification factor?
Skip if not applicable

* 14. Please provide the employee count and payroll information for animal handlers in your practice.
Enter zero (0) for groups that do not apply

* 15. Please provide the employee count and payroll information for clerical staff in your practice.
Enter zero (0) for groups that do not apply