Veterinarian Professional Liability Insurance Application

Veterinarian Professional Liability Insurance Application

Safehold Special Risk, Inc. / Hanover Insurance Group issuing carrier / AM Best Rating: A XIV

Applicant Type

New Policy Renewal Policy

Delivery Method

Email Mail

INDIVIDUAL APPLICANT INFORMATION

Applicant Name:

Mailing Address:

Street Address:

Phone No. (Office): Residence:

Fax No.: Email Address:

Employed By (If Applicable):

Employer’s Address:

Practice Type / Coverage Desired / Annual Premium

Small Animal — $225

Mixed Animal — $410

Large Animal — $995

Equine (majority) — $2,900

Coverages

Professional Liability — $2,000,000 each occurrence / $2,000,000 aggregate limit

Veterinary Medical Board Legal Defense — $100,000 each occurrence / $100,000 aggregate limit

Animal Bailee — $50,000 each occurrence / no limit per animal

Definitions

Small Animal — 100% small animal

Mixed Animal — 75% or greater small animal (including equine)

Large Animal — greater than 25% large animal (including equine)

Equine — 70% or greater equine

Veterinary License No.: State Licensed: Date Graduated:

Is the name on the license the same as applicant's name above: Yes No

If No, please explain:

Describe type of animals you will generally deal with:

Additional Professional Questions

Do you specialize in any specific fields of veterinary medicine (e.g., animal dentistry, dermatology, etc.)? Yes No

If yes, please explain:

Which insurance company provided your previous Professional Liability Insurance:

Has any insurance company cancelled or refused to issue Professional Liability insurance for you? Yes No

If yes, please explain:

Any professional liability claims or allegations during the last 3 years: Yes No

If yes, please give brief details and list amount paid for each claim:

Effective Date

Should a later date be required please indicate date here:

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

I hereby declare that the foregoing information is true and I have not concealed or misrepresented any material fact(s), and I agree that this application shall be the basis for Veterinary Professional Liability insurance I am applying for, and I understand it is for my own individual protection.

TO PAY BY CHECK

Make check out to: Safehold Special Risk, Inc.

Mail completed application and premium payment to:

Safehold Special Risk, Inc.

Veterinary Insurance Program

Attn: Shannon Gianatasio

10940 White Rock Road, 2nd Floor

Rancho Cordova, CA 95670-6076

If you have any questions, please contact:

Shannon Gianatasio: 916-767-0406 or shannon.gianatasio@safehold.com

TO PAY BY CREDIT CARD

Email or fax completed application and call Shannon to make a payment:

Email: Shannon.Gianatasio@safehold.com

Fax: 610-537-4264