PA Vet Insure
485 Mansfield Ave.
Pittsburgh, PA 15205
(412) 922-8222
mike@pavetinsure.com

 

 

Business Insurance Form Clinic Name: First Name: Last Name: Email: Requested Effective Date Type of business Sole Proprietor S-Type Corp LLC Other Phone Fax Years in Business? Web Site Street: City: State Zip Other Occupancies Other Occupancies Building limits Content Limits Building Age Construction Type Stories Building Improvements Wiring Plumbing HVAC Roof   Limit of Liability Annual Sales Annual Payroll Number of Veterinarians Number of Full time Employees Number of Part Time Employees Current Insurance Carrier Square Footage Premises     Please list Claims in the last 5 years   Date of Loss    Amount Paid    Open/Closed  Claim Information   Date of Loss    Amount Paid    Open/Closed  Claim Information   Date of Loss    Amount Paid    Open/Closed  Claim Information   Date of Loss    Amount Paid    Open/Closed  Claim Information   Date of Loss    Amount Paid    Open/Closed  Claim Information   Additional Comments: Please understand that there is no coverage bound until you receive confirmation in writing from Hurst-Weiss Insurance.