Laserfiche WebLink
AVMA PROFESSIONAL <br /> LIABILITY INSURANCE TRUST <br /> <br /> 2~9 SOUTH LA SALLE STREET CHICAGO. ILL~NO~S 60604 <br /> <br />PHONE: TOLL FREE - 800 ' 625-E360 IN ILLINOIS: CALL COLLECT - 312 · 346-1451 <br /> <br /> STATEMENT <br /> <br />REMITTANCE COPY <br /> <br />IN CONSIDERATION OF PAYMENT ON OR BEFORE <br />THE DUE DATE, IT mE, AGREED THAT THE COVERAGE <br /> <br /> ENDORSED BY <br /> <br /> AMERICAN <br />VETERINARY <br /> <br />MEDICAL ASSOCIATION <br /> <br />L / <br /> <br />!FFECTIVE DATE <br /> <br />PARTICULARS <br /> <br />TOTAL <br /> <br />[.a_~l~l~ PLEASE MAKE CHECK PAYABLE TO: AVMA PROFESSIONAL LIABILITY INSURANCE TRUST <br /> NUMBER OF VETERINARIANS EMPLOYED BY ABOVE NAMED PRAC- <br /> <br /> NmE OF <br /> <br />IF YOUR PRACTICE IS INCORPORATED AND YOU ARE THE OWNER, GIVE <br />ITS FULL NAME AND DESIGNATION. (APPLIES ONLY TO LICENSED SHAREHOLDERS) <br /> <br />'PLEASE LIST NAMES OF VETERINARIANS EMPLOYED BY YOU ON <br /> THE BACK OF THE REMITTANCE COPY. <br />CHANGE /'AY ADDRESS TO: <br /> <br /> REQUEST FOR INCREASED LIMITS OF LIABILITY <br />YOUR PRESENT LIMITS ARE: 2~,030 / 75,000 <br />INCREASE MY LIMITS TO: (PLEASE CIRCLEt <br /> lOO,O00 / 300, P.'q~ <br /> I ,0,)3,000 / 1 <br />J~J RETAIN MY PRESENT LIMITS OF LIABILITY <br /> <br />YOU ARE COVERED AT <br /> <br />YPES OF PLAN # 1 <br />3VERAGE <br />)n PRemises ~rozm LIMITS <br />eing Transported S15,000 <br />er Animal 3,000 <br />innual Premium 1,500 <br />p.r~ LOCATION $50 <br /> <br /> ! WANT EXTENSION <br /> PLAN <br /> I t <br /> <br />LOCATION(S) FOR PLAN <br /> <br />YOU ARE NOT COVERED <br /> FOR THE EXTENSION <br /> <br />PLAN # 2 PLAN # 3 PLAN # 4 PLAN # 5 PLAN # 6 PLAN # ? pLAN # 8 PLAN # 9 <br />LIMITS LIMITS LIMITS LIMITS LIMITS LIMITS LIMITS LIMITS <br />$30,000 $45,000 $60,000 575,000 S90,000 $120,000 S180,000 $250,000 <br />6,000 9,000 12,000 15,000 18,000 24,000 36,000 50,000 <br />3,000 4.500 6,000 7,500 9,000 12,000 18,000 25,000 <br />$Ioo $15o $2oo $250 $300 $400 $600 $800 <br /> NUMBER OF LOCATIONS ~ I AM NOT INTERESTED AT THIS TIMEJ J <br /> TO BE COVEREDJ J IN THE EXTENSION COVERAGE <br /> I I <br /> <br /> <br />