Veterinarians and Pet – Hutch BusinessBusiness name:Legal entity:First ChoiceSecond ChoiceThird ChoiceNumber of employees:Contact name: First Last Phone:Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCĂ´te d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRĂ©unionSaint BarthĂ©lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTĂĽrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweĂ…land Islands Country Other location(s): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCĂ´te d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRĂ©unionSaint BarthĂ©lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTĂĽrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweĂ…land Islands Country Email: Website / Social Media:Annual sales:Annual payroll:Federal tax ID number:Franchise:YesNoCurrent carrier:Years with current carrier:Policy expiration date: MM slash DD slash YYYY Number of claims:Claim(s) details:UnderwritingHas the Applicant ever been canceled (incl. nonpay) or refused insurance of any kind by ERIE or any other insurance carrier?YesNoIf yes, please explain:Has the Applicant filed for bankruptcy in the past 5 years?YesNoIf yes, please explain:GeneralDoes the Applicant work with anything other than domestic animals?YesNoDoes the Applicant sell exotic animals?YesNoIf yes, what kind of exotics?Does the Applicant provide services for high value, prize, racing, show, and/or exotic animals?YesNoDoes the Applicant provide kenneling / boarding?YesNoDoes the Applicant provide mobile services?YesNoDoes the Applicant keep controlled substances on site?YesNo(If yes, Central Station Burglar Alarm required)If yes, where / how kept and secured as per any state and federal guidelines?Does the Applicant operate a crematorium on site?YesNoDoes the Applicant operate as a shelter?YesNoDoes the Applicant operate as a breeder?YesNoDoes the Applicant operate as a training or obedience school?YesNoDoes the Applicant offer any other off premises services?YesNo(ie: in home pet sitting/dog walking)Does the Applicant provide transporting of animals?YesNoFire and Burglary ProtectionIs there a burglar alarm?YesNoMonitored by central station?YesNo(Required if controlled substances kept on site)Is there a fire alarm?YesNoMonitored by central station?YesNoAutomatic Sprinkler System?YesNoIf yes, provide annual service date.Professional LiabilityAre all professional employees of the Applicant licensed as required by law?YesNoIs the Applicant a member of a local or national pet care organization?YesNoIf yes, provide name.Do any licensed employees work for others in addition to the Applicant?YesNoIf yes, explain:Has the Applicant, the applicant’s business, or any of the applicant’s employees had a professional liability claim within the last five years?YesNoGeneral PremisesHours of operation?Year of roof:Roof type:AsphaltShinglesMetalSlate/TileSlate/TileRoof condition:ExcellentGoodFairPoorRoof concerns:NoneSaggingMissing shinglesWorn shinglesBurglar Alarm:CentralCentralLocalOutside Lighting:AdequateInadequatePeeling / Flaking paint?YesNoIf yes, where?Any Deterioration / Dry Rot?YesNoIf yes, where?Foundation condition:GoodCrackingDisrepairWalking surfaces:GoodUnlevelHolesHeating type:ElectricGasOilHeating condition:GoodPoorElectrical condition:GoodPoorOverall Housekeeping?ExcellentGoodFairPoorPropertyBlanketYesNoDeductible amount:Building value:Additional Property (signs, lights, clocks, fences, playgrounds, etc.)Construction type:Protection class:Year built:Building square footage:Applicant square footage:Number of stories:List other tenants: Add RemoveSewer / Drain:Employee dishonesty:Computer coverage:Include enhancement endorsementYesNoGeneral Liability LimitSelect one:300 / 600500 / 10001000 / 2000Umbrella?YesNoRating basis:Sales / Receipts:Payroll:Data Breach liability:Employee benefit liability:Employment practices liability:Deductible:Number of Employees (full-time):Number of Employees (part-time):Third-party coverage?YesNoWorkers’ CompensationMaterial handling / back injury prevention program?YesNoSafe Practices / Animal handling training?YesNoAre exit doors easily accessible and unblocked?YesNoExpert modification factor:Expert modification date: MM slash DD slash YYYY Sole proprietor / Partners coverage?YesNoCorporate officer coverage?YesNoListClass code #:Payroll = Add RemoveAverage length of employment:Safety: Safety meetings Lifting training Forklift training PPE training (check all that apply)Eye washing stations?YesNoAutosAuto used in business?YesNoAutos titled to?Hired / Non-owned?YesNoDo your corporate officers maintain a personal auto policy?YesNoIf no, consider adding the corporate officers named coverage endorsement.LiabilityMed PayUm / UimCompCollListYearMakeModelVIN Add RemoveDocuments Exterior photos of front and back Interior photos of waiting room, exam room, kennel/boarding area Loss runs Check each box when complete: