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Veterinarian_Questionnaire

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					                                                                                                         Veterinarian Questionnaire

                                                                                                                                          Page 1 of 3


Applicant’s name: _______________________________________________________________________________________________

Address: _______________________________________________________________________________________________________
              Street                                                                       City                       State            Zip

Applicant’s website address: ____________________________________ Contact’s email address: ______________________________




GENERAL INFORMATION

    1.   How long have you been in business?                                                                          ________________________


    2.   Does your company operate under different company names?                                                        Yes            No
         a.   If yes, please list the names: ____________________________________________________________________________
         _______________________________________________________________________________________________________

         b.   What are the operations of each? ________________________________________________________________________

         c.   What percent of total receipts of the named insured is each? __________________________________________________


    3.   Are you a member of any professional or trade organizations?                                                    Yes            No
         a.   If yes, please list ______________________________________________________________________________________
         ________________________________________________________________________________________________________


    4.   In what state(s) do you conduct business? ______________________________________________________________________


    5.   Please indicate the number of employees:                         Full-time _______________                   Part-time ______________
         “Employees” include: Sole proprietors, Partners, Executive Officers, Seasonal employees, Part-time employees, Full-time employees.


    6.   What pre-employment screening is used? Please explain: _________________________________________________________
         _______________________________________________________________________________________________________


    7.   Is any work sub-contracted?                                                                                      Yes            No
         a.   If yes, what type of work is sub-contracted out? _____________________________________________________________
         b.   What is the total cost of the subcontracted work? ____________________________________________________________
         c.   Do you obtain a certificate of insurance from the subcontractors?                                           Yes            No


    8.   Have you had any losses in the last five years?                                                                  Yes            No
         a.   If yes, please provide date(s), and explain _______________________________________________________________
              _________________________________________________________________________________________________
              _________________________________________________________________________________________________




   Questions? 630-762-9090 | Please email completed forms to Kevin Morency kmorency@feltesinsurance.com | Fax: 630-762-1311
                           Brian Feltes & Associates, 1020 Cedar Avenue, Suite 209, St. Charles, IL 60174
                                                                                                        Veterinarian Questionnaire

                                                                                                                                      Page 2 of 3


VETERINARY PRACTICE OPERATIONS

   1.   Are you a licensed veterinarian?                                                                               Yes           No

   2.   Are all veterinarians associated with your practice licensed?                                                  Yes           No

        a.    If yes, please list (or attach separate sheet listing hired veterinarians).

              ________________________________________________________________________________________________

        b.    If no, please explain ________________________________________________________________________________

              ________________________________________________________________________________________________

   3.   In the past 3 years, has any license investigation or action been taken against you or any employee?            Yes          No

        a.    If yes, please provide name(s), date(s), and explain ________________________________________________________
              _________________________________________________________________________________________________
              _________________________________________________________________________________________________


   4.   How would you describe your practice?
                   Small-animal practice                                                    Food animal / livestock practice
                   Mixed, predominantly small-animal practice                               Equine practice

   5.   Please check the box in front of any services that are provided and indicate what percentage that service makes up of the total
        operation:
             Small-animal services       _________%
             Equine services             _________%
             Livestock services          _________%
             Exotic animal services      _________%
             Grooming                    _________%
             Boarding                    _________%
             Obedience Training          _________%
             Pet Food Products           _________%
             Pet Care Products           _________%
             Crematorium                 _________% If yes, is crematorium composed of fire resistive construction?            Yes        No


   6.   What is total payroll (excluding owners, partners, officers)?             $_______________________________ Annual Payroll
        a.    Number of veterinarians                _______________
        b.    Number of veterinary technicians       _______________


   7.   How are medicine and drugs secured? ______________________________________________________________________
        _____________________________________________________________________________________________________
        _____________________________________________________________________________________________________



  Questions? 630-762-9090 | Please email completed forms to Kevin Morency kmorency@feltesinsurance.com | Fax: 630-762-1311
                          Brian Feltes & Associates, 1020 Cedar Avenue, Suite 209, St. Charles, IL 60174
                                                                                                  Veterinarian Questionnaire

                                                                                                                               Page 3 of 3


PROPERTY INSURANCE

    1.   Do you need Building Coverage?                                                                        Yes            No
         a.   If yes, requested amount?                                                                     $______________________
    2.   Do you need Content Coverage?                                                                         Yes            No
         a.   If yes, requested amount?                                                                     $______________________
    3.   Do you need Equipment Coverage?                                                                       Yes            No
         a.   If yes, total value to insure for?                                                            $______________________
         b.   If yes, type of cost to insure for?                                                    Replacement Cost        Actual Cost

COMMERCIAL UMBRELLA

    1.   Do you need a Commercial Umbrella?                                                                    Yes            No
    2.   If yes, limit of liability needed?                                                                 $______________________

COMMERCIAL AUTOMOBILE

    1.   Does the business title any automobiles or other operating vehicles in the business name?             Yes            No


    2.   Is insurance coverage needed for owned automobiles?                                                   Yes            No


         a.   If yes, describe your Vehicle(s) Make, Model, and Year:            ________________________________________________
              ____________________________________________________________________________________________________
         b.   If yes, limit of liability desired?                                                           $_______________________
         c.   If yes, deductible desired?                                                                   $_______________________


    3.   Do any of the employees, owners or officers drive personally owned automobiles/other
         vehicles in the course of their work?                                                                 Yes            No
         a.   If yes, how many?                                                                             ________________________
         b.   Are they required to carry personal auto insurance?                                              Yes            No
         c.   Limits?                                                                                       $_______________________




The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any
material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.


_____________________________________________________________________________________                                   ______________
                                Applicant’s Signature                                                                         Date


________________________________________            ____________________________________________________                ________________
         Agent’s Signature                                           Agency Name                                              Date




   Questions? 630-762-9090 | Please email completed forms to Kevin Morency kmorency@feltesinsurance.com | Fax: 630-762-1311
                           Brian Feltes & Associates, 1020 Cedar Avenue, Suite 209, St. Charles, IL 60174

				
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