Veterinarians and Pet - Hutch

Veterinarians and Pet – Hutch

Business

Business name:

Legal entity:

Number of employees:

Contact name:

First Last

Phone:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other location(s):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

Website / Social Media:

Annual sales:

Annual payroll:

Federal tax ID number:

Franchise:

Current carrier:

Years with current carrier:

Policy expiration date:

Number of claims:

Claim(s) details:

Underwriting

Has the Applicant ever been canceled (incl. nonpay) or refused insurance of any kind by ERIE or any other insurance carrier?

If yes, please explain:

Has the Applicant filed for bankruptcy in the past 5 years?

If yes, please explain:

General

Does the Applicant work with anything other than domestic animals?

Does the Applicant sell exotic animals?

If yes, what kind of exotics?

Does the Applicant provide services for high value, prize, racing, show, and/or exotic animals?

Does the Applicant provide kenneling / boarding?

Does the Applicant provide mobile services?

Does the Applicant keep controlled substances on site?

(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?

Does the Applicant operate as a shelter?

Does the Applicant operate as a breeder?

Does the Applicant operate as a training or obedience school?

Does the Applicant offer any other off premises services?

(ie: in home pet sitting/dog walking)

Does the Applicant provide transporting of animals?

Fire and Burglary Protection

Is there a burglar alarm?

Monitored by central station?

(Required if controlled substances kept on site)

Is there a fire alarm?

Monitored by central station?

Automatic Sprinkler System?

If yes, provide annual service date.

Professional Liability

Are all professional employees of the Applicant licensed as required by law?

Is the Applicant a member of a local or national pet care organization?

If yes, provide name.

Do any licensed employees work for others in addition to the Applicant?

If 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?

General Premises

Hours of operation?

Year of roof:

Roof type:

Roof condition:

Roof concerns:

Burglar Alarm:

Outside Lighting:

Peeling / Flaking paint?

If yes, where?

Any Deterioration / Dry Rot?

If yes, where?

Foundation condition:

Walking surfaces:

Heating type:

Heating condition:

Electrical condition:

Overall Housekeeping?

Property

Blanket

Deductible 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:

Sewer / Drain:

Employee dishonesty:

Computer coverage:

Include enhancement endorsement

General Liability Limit

Select one:

Umbrella?

Rating 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?

Workers’ Compensation

Material handling / back injury prevention program?

Safe Practices / Animal handling training?

Are exit doors easily accessible and unblocked?

Expert modification factor:

Expert modification date:

Sole proprietor / Partners coverage?

Corporate officer coverage?

List

Class code #:

Payroll =

Average length of employment:

Safety:

Safety meetings

Lifting training

Forklift training

PPE training

(check all that apply)

Eye washing stations?

Autos

Auto used in business?

Autos titled to?

Hired / Non-owned?

Do your corporate officers maintain a personal auto policy?

If no, consider adding the corporate officers named coverage endorsement.

Liability

Med Pay

Um / Uim

Comp

Coll

List

Year

Make

Model

VIN

Documents

Exterior photos of front and back

Interior photos of waiting room, exam room, kennel/boarding area

Loss runs

Check each box when complete: