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Annual Premiums Effective January 1_ 2011

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Annual Premiums Effective January 1_ 2011 Powered By Docstoc
					                        Annual Premiums Effective January 1, 2011
                                                          (for all states except California)

                                              Primary Professional Liability Insurance
                        Please see reverse side for a detailed list of insurance rating codes. State and local taxes may apply.

      Plan     Limits                                       Equine           Food Animal            Mixed Practice                Small Animal
               (per claim/aggregate)                                                                Predominantly Small
                                                              Class I                  Class II                Class III                    Class IV

      1          100,000/300,000                          $ 1,807                      $ 672                    $ 257                        $ 182
      2          300,000/900,000                            2,107                        782                      287                          202
      3      1,000,000/3,000,000                            2,782                        967                      347                          234

                                               Excess Professional Liability Insurance
                                           Must have $1,000,000/3,000,000 Primary Limits
      Plan     Limits
               (per claim/aggregate)                        Equine           Food Animal            Mixed Practice                Small Animal
                                                                                                    Predominantly Small

      1      1,000,000/1,000,000                             $ 506                     $ 249                    $ 130                         $ 100
      2      2,000,000/2,000,000                                823                      405                      212                           163
      3      3,000,000/3,000,000                              1,088                      535                      280                           216
      4      4,000,000/4,000,000                              1,278                      629                      329                           254
      5      5,000,000/5,000,000                              1,417                      697                      365                           281
          Excess insurance is professional liability coverage that can be purchased in addition to primary plan 3 only.
                              Higher limits are available upon request. Call the PLIT for more information.

                                        Professional Extension Endorsement (Animal Bailee)
                                               Available to owners, partners, and shareholders.
   Total Limits of
   Liability                 Plan #1        Plan #2         Plan #3         Plan #4        Plan #5         Plan #6           Plan #7            Plan #8
   Any One Animal             $2,000         $4,000          $6,000          $8,000        $10,000         $16,000           $20,000            $25,000
   Transportation              6,000         12,000          18,000          24,000         30,000          48,000            60,000             75,000
   Per Specified Premises     25,000         50,000          75,000         100,000        130,000         200,000           250,000            315,000


   Annual Premium                 $16             $26            $36             $46              $56            $66                $76               $86
   (Per Location)
                                                                                                                           The Professional Extension Endorse-
   Total Limits of                                                                                                         ment (Animal Bailee) protects your
                                                                                                                           business from losses due to injury or
   Liability                  Plan #9           Plan #10          Plan #11          Plan #12           Plan #13            death of animals in your care, custody
                                                                                                                           and control from causes unrelated
   Any One Animal             $50,000           $100,000          $250,000          $500,000         $1,000,000            to treatment. Coverage provided for
                                                                                                                           injuries to and death of animals due to:
   Transportation             150,000            300,000           750,000         1,000,000          1,000,000            fire and lightning; windstorm and water
                                                                                                                           damage; theft and vandalism; escape
   Per Specified Premises     625,000          1,000,000         1,000,000         1,000,000          3,000,000            (except for mysterious disappearance);
                                                                                                                           automobile accidents; injuries from
                                                                                                                           other animals. Coverage also includes
                                                                                                                           charges that are uncollectible as a
   Annual Premium               $1,328             $2,273               $2,682         $3,303              $4,613          result of loss or damage to your client’s
                                                                                                                           animal, and direct physical loss or
   (Per Location)
                                                                                                                           damage to animal accessories (subject to
                                                                                                                           policy terms, limitations and exclusions).



    Veterinary Professional Liability Regulatory Action Defense Coverage (also known as Veterinary License Defense)
Coverage provides up to $25,000 in legal fees to defend actions against licenses required for the practice of veterinary
medicine for an annual premium of $69. This covers disciplinary issues that arise out of incidents that occur after the date
coverage is secured (subject to policy terms, conditions, and exclusions).
If you have had a regulatory action taken against any veterinary license in the past three years, you must wait three years from the date
of the regulatory action to apply for this endorsement. 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. If you are involved in an
ongoing investigation, you are not eligible for coverage. Please contact us when the outcome has been finalized to determine eligibility.
                               AVMA PLIT Insurance Rating Codes (IRC)
                 Equine                                Food Animal                           Mixed Practice                         Small Animal
                 Class I**                             Class II                          Class III                                  Class IV
       11        Predominantly               10        Bovine Exclusive            16    Mixed Practice                   17        Small Animal
                 Equine**                    12        Porcine Exclusive                 (Predominantly                             Exclusive
       *24A      Pathology                   13        Food Animal                       Small Animal)                    *24D      Pathology
       *27A      Radiology                             Exclusive                   *24C Pathology                         *27D      Radiology
       *29A      Surgery                     14        Mixed Practice              *27C Radiology                         *29D      Surgery
       *82A      Ophthalmology                         (Predominantly              *29C Surgery                           *36D      Regulatory
       *83A      Nutrition                             Food Animal)                *36A, Regulatory                                 Veterinary Medicine
       *84A      Clinician                   15        Mixed Practice               B, C Veterinary Medicine              *82D      Ophthalmology
       *85A      Theriogenology              18        Poultry                           (except small animal)            *83D      Nutrition
       *86A      Anesthesiology              00        Ratites                     *82C Ophthalmology                     *84D      Clinician
       *87A      Internal Medicine           *24B      Pathology                   *83C Nutrition                         *85D      Theriogenology
       *88A      Cardiology                  *27B      Radiology                   *84C Clinician                         *86D      Anesthesiology
       *89A      Dermatology                 *29B      Surgery                     *85C Theriogenology                    *87D      Internal Medicine
       *90A      Neurology                   *82B      Ophthalmology               *86C Anesthesiology                    *88D      Cardiology
       *91A      Epidemiology                *83B      Nutrition                   *87C Internal Medicine                 *89D      Dermatology
       *92A      Oncology                    *84B      Clinician                   *88C Cardiology                        *90D      Neurology
                                             *85B      Theriogenology              *89C Dermatology                       *91D      Epidemiology
                                             *86B      Anesthesiology              *90C Neurology                         *92D      Oncology
                                             *87B      Internal Medicine           *91C Epidemiology                      32        Teaching/ Research
                                             *88B      Cardiology                  *92C Oncology                          42        Wildlife, Zoo, and
                                             *89B      Dermatology                                                                  Fur Bearing
                                             *90B      Neurology                                                          94        Avian
                                             *91B      Epidemiology
                                             *92B      Oncology

       The following definitions are used in determining appropriate Insurance Rating Codes:
       Exclusive:            Means 90% or more of the individual’s professional activity is derived from a single species or identified group.
        **Predominantly:        Please note the classification change for Class I. For equine practice activity, predominantly means 70% to
                                100% of the individual’s professional activity is derived from equines. Equine exclusive is no longer an IRC.
                                For all other species and identified groups, predominantly means 70% to 89% of the individual’s professional
                                activity is derived from a single species or identified group.
       Mixed Practice:          Means 30% to 69% of the individual’s professional activity is derived from a single species or identified group, or
                                less than 70% is attributable to a single species or identified group.
       Ratites and Poultry:     The Trust classifies cervidae, poultry and ratites as food animals. Please evaluate classification accordingly.

             *The suffix indicated reflects the species identified with professional activities, as follows:
              Suffix Activity                                                               Suffix Activity
              A       Predominantly Equine                                                  C          Mixed Practice (Predominantly Small Animal)
              B       Bovine Exclusive; Porcine Exclusive; Food Animal                      D          Small Animal Exclusive.
                      Exclusive; Mixed Practice (Predominantly Food Animal);
                      Predominantly Ratite; Mixed Practice; Cervidae; Poultry

       IMPORTANT NOTES:                        • All veterinarians must have their own individual certificates.
       • The insured veterinarian must be an active member of the AVMA (800-248-2862) and licensed to practice in his or her state of residence or
         primary practice, or otherwise legally practicing.
       • Coverage for storage of embryos and semen is not provided by the primary professional liability, excess professional liability, or extension (animal
         bailee) coverages. If coverage is desired, contact the PLIT at 800-228-7548.
                                            AVMA PLIT • P.O. Box 1629 Chicago, IL 60690-1629
       Phone 800-228-PLIT (7548) • Fax 888-PLIT-FAX (754-8329) • Fax-on-Demand 888-740-PLIT • info@avmaplit.com • www.avmaplit.com
      Business Property/Liability • Flood • Umbrella Liability • Workers' Compensation • Commercial Auto (Special Coverage for Mobile Practitioners) •
 Employment Practices Liability • Professional Liability • Professional Excess • Professional Extension (Animal Bailee) • Veterinary License Defense • Student
Liability • Directors and Officers Liability (Protection for Board Members) • Personal Lines (Auto, Homeowners, Renters) • Safety and Loss Control Resources
         Trust Broker and Consultant since 1962: HUB International Midwest Limited • HUB International Midwest Insurance Agency (CA)
Maryland Fraud Statement


TO BE ATTACHED TO AND FORM PART OF THE APPLICATION.


ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION
IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.




                                                                            U-GU-839-A (09/09)
                                                                                    Page 1 of 1
Rhode Island Fraud Statement


TO BE ATTACHED TO AND FORM PART OF THE APPLICATION.


ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR
BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY
OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.




                                                                              U-GU-845-A (02/10)
                                                                                      Page 1 of 1
                                                                                                                                                         870
APPLICATION FOR:                     AVMA PLIT-sponsored Professional Liability
                                                                                                            Sponsored
                                     Insurance Program
                                                                                                               by the
Trust Broker and Administrator:                     Hub International Midwest Limited
Underwritten by:                                    Zurich American Insurance Company

You must be an active member of the AVMA and licensed to practice in
your state of residence or primary practice, or otherwise legally practicing
(subject to policy terms, conditions and exclusions).

     aPPliCant information

I am a(n):            employee                    sole proprietor         partner            shareholder of a corporation           other:

Applicant’s name:                                                                                                                      DVM      VMD

Mailing address:

City/ State/ Zip:

Contact name:
                             indicate if different than applicant name

Office phone:            (          )                                                          Other phone: (           )

Fax:                     (          )                                                          Email:

     Professional liability Coverage

Are you an active AVMA member?                            Yes  No                    AVMA member number:

Are you licensed in the state of your residence or principal practice?                          Yes  No

       If not licensed, please explain:

Insurance Rating Code (IRC) (see rate card):



Please circle limit plan desired (see rate card):                                       Primary Plan             1•2 •3

                                                                                        Excess Plan              1•2•3•4•5
                                                                                        (Note: An Excess Plan can only be added to a Primary 3 Plan)


     Professional extension and/or embryo/ semen Coverages (Depending on your state, a separate bailee policy may be issued)

Indicate the location address and circle plan desired for each location. Coverage available to veterinarian owners/partners/shareholders.

Office locations:                                                                                                   Extension Plan                Embryo Plan
                                                                                                                  1 2•3•4•5•6•7•8
                                                                                                                    •
                                                                                                                                                  A•B•C•D•E
1:                                                                                                                 9 • 10 • 11 • 12 • 13
         address                                                                        city, state zip
                                                                                                                  1•2•3•4•5•6•7•8
                                                                                                                   9 • 10 • 11 • 12 • 13          A•B•C•D•E
2:
                                                                                                                  1•2•3•4•5•6•7•8
                                                                                                                   9 • 10 • 11 • 12 • 13          A•B•C•D•E
3:
                                                                                                                                                                0406
                 EMPLOYED VETERINARIANS MUST CARRY SEPARATE PROFESSIONAL
                      LIABILITY COVERAGE FOR THEIR OWN PROTECTION.

   veterinary liCense Defense for regulatory aCtions

       Yes                               Please add the Veterinary License Defense Endorsement to my professional liability certificate. I
                                          understand that this provides up to $25,000 in legal fees to defend actions against licenses required for
                                          my practice of veterinary medicine for an annual premium of $69 (subject to policy terms, conditions
                                          and exclusions).
 Yes  No                                Have you had a regulatory action taken against any license in the past three years?
 Yes  No                                Do you have any pending actions against any license, or are you currently under investigation?
PLEASE NOTE:                              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.

Payment options:                               Check enclosed (payable to AVMA PLIT)                                           Credit Card                Money Order

       To pay by credit card please complete the following:                                         Visa      Mastercard
       Card Number:                                                                                         Expiration Date:

       Credit Card Billing Address:
       Signature:                                                                                           Print Name:

       The above credit card will be charged the full premium billed for the remainder of the policy term unless otherwise indicated.
       Amount to be charged:


CheCk here if you wish to initiate Coverage:

                Please bind coverage effective 12:01 am the date following receipt of this application by your office. I will call
                 800-228-PLIT (7548) if I need coverage bound sooner. Enclosed is my annual premium payment.
                 Please call our office for a quotation.
I confirm that all information is correct to the best of my knowledge including the Insurance Rating Code (IRC) shown below.




irC                         insured signature                                                                                                                   Date signed
All references to coverage are subject to the policy terms, limitations and exclusions. The insurance
policy and not this application will form the contract between the insured and the insurance company.          Return this signed application along with your payment in the form of
                                                                                                               a check, money order, or credit card authorization in the enclosed enve-
                                                                                                               lope to: AVMA PLIT, P.O. Box 1629, Chicago, IL 60690-1629.
                            P.O. Box 1629
                            Chicago, IL 60690-1629                                                             Please call the PLIT office at 800-228-7548 if you have any questions.
                            Phone 800-228-PLIT (7548)
                            Fax 888-PLIT FAX (754-8329)
                            Fax-on-Demand 888-740-PLIT
                            Email i n f o @ a v m a p l i t . c o m                                            Trust Broker and Consultant since 1962:
                            www.avmaplit.com                                                                   Hub International Midwest Limited
                                                                                                               Hub International Midwest
                                                                                                               Insurance Agency (CA)

				
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