HomeMy WebLinkAbout2016-343-E Animal Svc - Claudia H. Sheppard, DVM for veterinary services DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
TITLE Claudia H. Sheppard, DMV
FY 2016-17
NORTH CAROLINA
ORANGE COUNTY
AN AGREEMENT FOR THE PROVISION OF CONSULTING VETERINARY
SERVICES AND THE PERFORMANCE OF SPAY/NEUTER SERVICES
This Agreement is between the County of Orange ("County") through the Animal Services
Department ("Department") and Claudia H. Sheppard, DVM, MS, ("Veterinarian") whose
address is 101 Autumn Lane, Chapel Hill, NC 27516, for the provision of consulting veterinary
services and the performance of spay/neuter surgery service
WITNESSETH
WHEREAS, the County has a need for the services of a veterinarian with whom to consult in
regard to practices and procedures regarding animal health and to provide in-house spay/neuter
surgery services for animals adopted from or available to be adopted from the Department; and
WHEREAS, Claudia H. Sheppard, DVM, MS, a licensed veterinarian in the State of North
Carolina desires to provide consultation and surgical services to Orange County through the
Animal Services Department.
NOW, THEREFORE, in consideration of the promises and of the mutual covenants hereinafter
set forth, Orange County and Claudia H. Sheppard agree to the following terms and conditions:
A. The Veterinarian agrees to the following:
1. Provide up to 8.5 hours per week of services including, but not limited to,
procedures for sterilization, examination and treatment in accordance with the
Department's standard operating guidelines; and
a. Surgical services shall be provided up to 8.5 hours per week, unless the
veterinarian is providing back up coverage in absence of the other
contracted veterinarian or otherwise approved by the Veterinary Health
Care Manager (or designee) (up to an additional 8.5 hours per week). The
surgical services shall be scheduled during the time period Monday
through Friday, 8:00 am to 3:00 pm (unless otherwise approved by the
Veterinary Health Care Manager); and
b. Perform sterilization surgery services on select animals by performing a
complete ovariohysterectomy for female animals and castration for male
animals; and
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c. Conduct a pre-surgical physical examination of the animal to determine
the animal's suitability for surgery. Any medical and physical
abnormalities that present upon examination will be documented in the
animal's medical record and communicated to the Veterinary Health Care
Manager(or designee). The Veterinarian shall consult with the Veterinary
Health Care Manager or appropriate designee prior to and concerning
decisions to disqualify an animal for surgery; and
d. Document the physical examination, any abnormalities, treatments and/or
surgical procedures performed for each animal in the animal's medical
record; and
2. Provide veterinary services that include, but are not limited to, basic veterinary
care for shelter animals and training for department staff to become certified
euthanasia technicians pursuant to the rules promulgated under the North Carolina
Animal Welfare Act; training for department staff to become Certified Rabies
Vaccinators in accordance with guidelines set forth by the North Carolina
Department of Health and Human Services Division of Public Health and as
provided in the "Memorandum of Understanding between Orange County Animal
Services, Orange County Health Director and Claudia H. Sheppard, MS, DVM"
which is attached as Exhibit A and hereby incorporated herein by reference;
training and supervision of any staff implementing electronic identification
devises ("microchips") into animals within the care of the Animal Services
Department and other training as deemed appropriate by the Veterinary Health
Care Manager and Animal Services Director.
3. Consult with the Department management staff to develop and monitor standard
operating guidelines that include, but are not limited to, animal health and
husbandry; disease outbreak and management and the care of individual animals
with infirmities; and
4. Provide up to 10 hours per/week of consultation services to the Department at a
level scheduled by the Veterinary Health Care Manager, including telephone
consultation and on-site veterinary services; consultation services to occur
Monday through Sunday; and after hour critical care for injured or ill animals on
the basis of a mutually agreed upon schedule.
5. Maintain a license to practice veterinary medicine, that is current and in good
standing, in the state of North Carolina as well as the level of expertise and
education necessary to keep abreast of current industry standards and practices;
and
6. Maintain professional liability insurance coverage with coverage of at least $1
million, per occurrence, $1 million aggregate while providing services to the
Department, proof of such insurance shall be submitted annually to the
Department; and
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7. Be a member in good standing of the American Veterinary Medical Association;
and
8. The Veterinarian agrees to defend, indemnify, and hold harmless the County, its
elected officials, employees or volunteers for all loss, liability, claims or expense
(including reasonable attorney's fees) arising from bodily injury, including death
or property damage, to any person or persons caused in whole or in part by the
negligence or misconduct of the Provider, except to the extent same are caused by
the negligence or willful misconduct of the County. It is the intent of this section
to require Provider to indemnify the County to the extent permitted under North
Carolina law; and
9. Comply with all applicable federal, State, and local laws, including non-
discrimination laws as may be applicable in fulfilling this agreement; and
10. The Veterinarian shall submit an invoice for services rendered to the Department
on a monthly basis, and the invoice shall differentiate hours of surgical and
consulting services.
B. The County agrees to:
1. Payment. Orange County shall reimburse the Veterinarian for an amount not to
exceed Twenty-Seven Thousand Five Hundred Dollars ($27,500) for services
rendered from July 1, 2016, to June 30, 2017, and as provided herein.
C. The Parties Agree to:
1. Term. The term of this Agreement shall be from July 1, 2016, through June 30,
2017, unless terminated sooner as provided herein.
2. Terms of Payment.
a. The County shall pay the Veterinarian for consultation and surgical
services at an hourly rate of Forty-Two Dollars ($42.00)per hour; and
b. Upon submission of an invoice, he County shall reimburse the
Veterinarian in an amount up to Eight Hundred Dollars ($800) for any
expenses related to performance of this Agreement, except those
performed in Section A.2.
c. Upon a submission of an invoice for Certified Rabies Vaccinator Training
or any other training as provided in Section A.2., the veterinarian shall
submit a log of their time for payment to the Department no later than
thirty(30) days from the first day of logged time.
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d. The Department shall pay the Veterinarian for services rendered within
thirty(30) days of an invoice properly submitted.
3. Termination of Prior Agreements and Amendments. This agreement supersedes
and nullifies any and all prior agreements between the County and Veterinarian
including the amendments related to these agreements.
4. Termination. This Agreement may be terminated at anytime without penalty by
either party, with or without cause, upon delivery of written notice of termination
furnished to the other party at least thirty days prior to termination of the
Agreement. In the event of such termination, any payment due shall be prorated
to the date of termination.
5. Notices. Any notice required by this Agreement shall be in writing and delivered
by certified or registered mail, return receipt requested to the following:
Orange County Provider's Name & Address
Attention: Claudia Sheppard,DVM
P.O. Box 8181 101 Autumn Drive
Hillsborough,NC 27278 Chapel Hill,NC 27516
6. OSHA Compliance. Orange County controls the facilities where the Veterinarian
works. It is agreed Orange County is primarily responsible for compliance with
the Occupational Safety and Health Act (OSHA) and comparable state laws and
regulations to the extent those laws apply to the Veterinarian.
7. Workers Compensation. Veterinarian is responsible for her own workers'
compensation.
8. Independent Contractor. The services which Veterinarian shall render under this
Agreement shall be as an independent contractor with respect to Orange County.
Nothing contained in this Agreement shall be construed to create the relationship
of principal and agent, or employer and employee, between Veterinarian and
Orange County.
9. Non-Appropriation. No provision of this Agreement shall be construed or
interpreted as creating a pledge of the faith and credit of the Orange County
within the meaning of any constitutional debt limitation. No provision of this
Agreement shall be construed or interpreted as creating a delegation neither of
governmental powers nor as a donation by a lending of the credit of Orange
County within the meaning of the Constitution of the State of North Carolina.
This Agreement shall and does not directly or indirectly or contingently obligate
the Orange County to make any payments beyond those appropriated in the sole
discretion of Orange County for any fiscal year in which this Agreement shall be
in effect. No deficiency judgment may be rendered against Orange County in any
action for breach of a contractual obligation under this Agreement and the taxing
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power of Orange County is not and may not be pledged directly or indirectly or
contingently to secure any monies due under this Agreement.
10. Entire Agreement. This Agreement contains the entire understanding of the
parties and shall not be altered, amended or modified except by an agreement in
writing executed by the duly authorized officials of both parties.
11. Governing Law. This Agreement and the duties, responsibilities, obligations, and
rights of respective parties hereunder shall be governed by the laws of the State of
North Carolina. By executing this Agreement Provider affirms that Provider and
any subcontractors of Provider are and shall remain in compliance with Article 2
of Chapter 64 of the North Carolina General Statutes. By executing this
Agreement Provider certifies that Provider has not been identified, and has not
utilized the services of any agent or subcontractor, on the list created by the State
Treasurer pursuant to G.S. 147-86.58.
12. Anti-Discrimination. Provider shall at all times remain in compliance with all
applicable local, state, and federal laws, rules, and regulations. Provider shall at
all times remain in compliance with all applicable local, state, and federal laws,
rules, and regulations including but not limited to all state and federal anti-
discrimination laws, policies, rules, and regulations and the Orange County Anti-
Discrimination Policy. Any violation of this requirement is a breach of this
Agreement and County may immediately terminate this Agreement without
further obligation on the part of the County. This paragraph is not intended to
limit and does not limit the definition of breach to discrimination.
13. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek
damages with respect to any provision of, or the performance or non-performance
of, this Agreement shall be brought in the General Court of Justice of North
Carolina sitting in Orange County, North Carolina. It is agreed by the parties that
no other court shall have jurisdiction or venue with respect to such suits or
actions. Binding arbitration may not be initiated by either Party, however, the
Parties may agree to nonbinding mediation of any dispute prior to the bringing of
such suit or action.
14. Signatures. This Agreement together with any amendments or modifications may
be executed electronically. All electronic signatures affixed hereto evidence the
intent of the Parties to comply with Article 11A and Article 40 of North Carolina
General Statute Chapter 66.
IN WITNESS WHEREOF, the parties have hereunto signed this Agreement on the day and
year listed below.
[SIGNATURE PAGE TO FOLLOW]
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DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
FOR CLAUDIA H. SHEPPARD, DVM, MS
, —DocuSigned by:
a...(,a Stvppa.-d 7/5/2016
Claud TREtii ppard, DVM, MS Date
75,,FOR A ntitHALF OF ORANGE COUNTY
61Akuit, tkA.wtwtt-IrStt,t1
406&7434&74SE44.7
Bonnie Hammersley, Orange County Manager Date
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DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
AV M A I P`I T Veterinary Professional Liability
Protecting you through it all. Insurance Policy
Certificate of Insurance
This policy provides occurrence coverage.Please review the policy carefully. ZURICH
ITEM 1:Insured by the stock company below and hereinafter called the Company
Zurich American Insurance Company U-VPL-103-A-CW(07/04)
ITEM 2:Named Certificate Holder,member number,IRC,and address Master Policy Number: Certificate Number:
EOL 5241302-11 VETPR0008742
Claudia H. Sheppard,DVM FOR INFORMATION OR TO FILE A CLAIM
101 Autumn Lane PLEASE CALL(800)228-7548
Chapel Hill,NC 27516-1101 ITEM 3:Policy Period
From: 01/01/2016
To: 01/01/2017
12:01 am Standard time at the address of the Named Certificate Holder
as stated herein
ITEM 4:Limits of Liability
Member Name Member No. IRC Class Each claim $ 1,000,000
Claudia Sheppard 120285 17 IV Aggregate $3,000,000
ITEM 5:Premium and coverage summary ITEM 6:Forms Attached at Issuance:
Primary Professional Liability $222.00 U-VPL-100-A CW(07/04);U-VPL-103-A CW(07/04);U-GU-1041-A(03/11);U-
Veterinary License Defense $85.00 VPL-128-A NC(10/04);U-VPL-155-A NC(10/04);U-VPL-102-B CW(06/11);U-
GU-319-F(01/09)
ITEM 7: Schedule of Plan Numbers and location(s)for Professional Extension
TOTAL DUE: $307.00 Endorsement(Animal Bailee)/Embryo and Semen Storage(if purchased):
For additional locations,please see the attached page
Location Number/Address Extension Plan Embryo Plan
ITEM 8:Veterinary Professional Liability Regulatory Action License Defense
Coverage endorsement(if purchased): This Certificate of Insurance is issued off the Master Policy held by the American
Veterinary Medical Association(AVMA)Professional Liability Insurance Trust.By
Limit: $25,000 acceptance of this policy the Named Certificate Holder agrees that the statements in
the certificate and the application and any attachments hereto are the Named
Authorized Signature Certificate Holder's agreements and representations and that this policy embodies all
agreements existing between the Named Certificate holder&the Company or any
of its representatives relating to this insurance.
Notice to the Company: Zurich North American-Specialties Claims
Attn:Professional Liability Claim Department
Neil R.Hughes,President
P.O.Box 307010,Jamaica,NY 11430-7010
HUB International Midwest Limited
DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
Advisory notice to policy holders regarding the 9
rY p Y 9 9
U.S. Treasury Department's Office of Foreign ZURICH
Assets Control("OFAC") regulations.
No coverage is provided by this policyholder notice nor can it be constructed to replace any provisions of your policy. You
should read your policy and review your declarations page for complete information on the coverages you are provided.
This notice provides information concerning possible impact on your insurance coverage due to directives issued by the
U.S. Treasury Department's Office Assets Control ("OFAC").
Please read this Notice carefully.
OFAC administers and enforces sanctions policy based on Presidential declarations of"national emergency". OFAC has
identified and listed numerous:
• Foreign agents;
• Front organizations;
• Terrorists
• Terrorists organizations; and
• Narcotic traffickers;
as "Specially Designated Nationals and Blocked Persons." This list can be located on the United States Treasury's web
site— http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.
In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the
benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and Blocked Person, as
identified by OFAC, this insurance will be considered blocked or frozen contract and all provisions of this insurance are
immediately subject to OFAC restrictions. When an insurance policy is considered to be such a blocked or frozen
contract, no payments or premium refunds may be made without authorization from OFAC. Other limitations on premiums
and payments also apply.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
U-GU-1041-A(3/11)
Page 1 of 1
DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
Endorsement 9
North Carolina Amendatory Endorsement ZURICH
Certificate No. Eff.Date of Cert. Exp.Date of Cert. Eff.Date of End. Add'!Prem. Return Prem.
VETPRO008742 01/01/2016 01/01/2017 $307.00 $0.00
Named Certificate Holder and Mailing Address: Producer:
HUB International Midwest Limited
Claudia H. Sheppard,DVM 55 East Jackson Boulevard
101 Autumn Lane Chicago,IL 60604-4187
Chapel Hill,NC 27516-1101
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Veterinary Professional Liability Insurance Policy
It is agreed that Section IV—CONDITIONS,Paragraph D is deleted in its entirety and replaced with the following:
1. CANCELLATION
a. This policy may be canceled by the Named Certificate Holder by surrender of the policy to the Company or by mailing
written notice to the Company stating when such cancellation shall take effect. If canceled by the Named Certificate
Holder,the Company shall retain the customary short-rate proportion of the premium. In no event may the requested date of
cancellation be greater than ten(10) days prior to the date the request is received by the Company.
b. If this policy has been in effect less than sixty (60) days, the Company may cancel this policy for any reason by mailing
written notice by certified mail to the Named Certificate Holder at the address shown in the Certificate of Insurance, and
mailing to the producer of record, if any. Such cancellation shall be no fewer than fifteen(15) days from the date the notice
is mailed. Such notice shall state the reason for cancellation and if applicable be accompanied by a refund of unearned
premium,except a premium that has been financed.
c. If this policy is in effect sixty(60) days or more,the Company may cancel this policy for the following reasons:
(1) Nonpayment of premium in accordance with the policy terms;
(2) An act or omission by the Named Certificate Holder or his representative that constitutes material misrepresentation
or nondisclosure of a material fact in obtaining the policy, continuing the policy, or presenting a Claim under the
policy;
(3) Increase hazard or material change in the risk assumed that could not have been reasonably contemplated by the parties
at the time of assumption of the risk;
(4) Substantial breach of contractual duties,conditions,or warranties that materially affects the insurability of the risk;
(5) A fraudulent act against the company by the Named Certificate Holder or his representative that materially affects the
insurability of the risk;
(6) Willful failure by the Named Certificate Holder or his representative to institute reasonable loss control measures that
materially affect the insurability of the risk after written notice by the company;
(7) Loss of facultative reinsurance,or loss of or substantial changes in applicable reinsurance as provided in G.S.58-41-30;
(8) Conviction of the Insured of a crime arising out of acts that materially affect the insurability of the risk;or
(9) A determination by the commissioner that the continuation of the policy would place the Company in violation of the
laws of the state of North Carolina.
If the Company cancels subject to c(1) through c(9) above, the Company will mail by certified mail to the Named
Certificate Holder at the address shown in the Certificate of Insurance,and mail to the producer of record,if any.
Written notice of cancellation shall take effect fifteen(15) days from the date of mailing for the reasons set forth in c(1)
through c(9)above.
Any written notice of cancellation subject to c(1) through c(9) will state the reason for such cancellation and will be
accompanied by a refund of unearned premium,except a premium that has been financed.
d. If notice is mailed,proof of mailing will be sufficient proof of notice.
e. The Company shall refund the unearned premium computed at customary short rates if the policy is terminated by
the Named Certificate Holder. Under any other circumstances the refund shall be computed pro rata.
U-VPL-128-A-NC(09/04)
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DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
2. NONRENEWAL
a. If the Company elects not to renew this policy,the Company shall mail by certified mail to the Named Certificate Holder at
the address shown in the Certificate of Insurance, and mail to the producer of record, if any, written notice of nonrenewal.
The Company may refuse to renew a policy that has been written for a Policy Period of one (1)year or less at the policy's
expiration date by mailing written notice of nonrenewal to the Named Certificate Holder at the address shown in the
Certificate of Insurance at least forty-five (45) days prior to the expiration date of the policy. The Company may refuse to
renew a policy that has been written for a Policy Period of more than one (1)year at the policy anniversary date by mailing
written notice of nonrenewal to the Named Certificate Holder at the address shown in the Certificate of Insurance at least
forty-five(45) days prior to the anniversary date of the policy.
b. The Company must file a plan with the commissioner at least fifteen (15) days before the issuance of a nonrenewal because
of loss or reduction of reinsurance.
c. If notice is mailed,proof of mailing will be sufficient proof of notice.
d. If either one of the following occurs,the company is not required to provide written notice of nonrenewal:
(1) The Named Certificate Holder has insurance elsewhere;
(2) The Named Certificate Holder has obtained replacement coverage or agreed in writing to do so;or
(3) The Named Certificate Holder has requested or agreed to nonrenewal.
e. The policy may not be extended to meet nonrenewal notice requirements in a.above.
d. The transfer of a policy between companies within the same insurance group or changes in premium, Limit of Liability or
coverage are not refusals to renew.
3. CONDITIONAL RENEWAL
a. If the Company elects to renew this policy and the renewal is subject to the following:
(1) reduction in coverage;
(2) impose any kind of surcharge;or
(3) increase premium rate.
b. If the policy being conditionally renewed was written for a Policy Period of one (1) year or less, the renewal terms and
statement of premium due must be mailed at least forty-five (45) days before the expiration date of the policy. If the policy
being conditionally renewed was written for a Policy Period of more than one (1) year, the renewal terms and statement of
premium due must be mailed at least forty-five (45) days before the anniversary date of that policy. The Company shall mail
or deliver by certified mail written notice of the changes to the Named Certificate Holder at the address shown in the
Certificate of Insurance,and mailed to the producer of record,if any.
c. If the Company fails to furnish the conditional renewal terms and statement of premium due in the manner required in b
above, the Named Certificate Holder may cancel the renewal policy within the thirty (30) day period following receipt of
the conditional renewal terms and statement of premium due. For refund purposes, earned premium for any period of
coverage shall be calculated pro-rata upon the premium applicable to the policy being renewed instead of the renewal policy.
d. If the Company fails to comply with the forty-five (45) day written notice requirement in b. above, the Named Certificate
Holder is entitled to the option of coverage under the policy being renewed and at the same cost of that policy until forty-five
(45)days have elapsed after the Company has provided the Named Certificate Holder with the notice.
e. If a policy has been issued for a Policy Period longer than one (1)year, and for additional consideration a premium has been
guaranteed for the entire Policy Period, it is unlawful for the Company to increase that premium or other policy or coverage
provisions less favorable to the Named Certificate Holder during the term of the policy.
All other terms,conditions and exclusions of this policy remain unchanged.
/4/Signed by: i<- — 10/6/2015
Date
Authorized Representative
U-VPL-128-A-NC(09/04)
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DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
Endorsement 9
North Carolina Amendatory Endorsement ZURICH
Certificate No. Eff.Date of Cert. Exp.Date of Cert. Eff.Date of End. Add'!Prem. Return Prem.
VETPRO008742 01/01/2016 01/01/2017 $307.00 $0.00
Named Certificate Holder and Mailing Address: Producer:
HUB International Midwest Limited
Claudia H. Sheppard,DVM 55 East Jackson Boulevard
101 Autumn Lane Chicago,IL 60604-4187
Chapel Hill,NC 27516-1101
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Veterinary Professional Liability Insurance Policy
It is agreed that the Veterinary Professional Liability Bailee Extension Endorsement, U-VPL-101-A CW (07/04), Section IV—
ADDITIONAL CONDITIONS,Paragraph I is deleted in its entirety and replaced with the following:
I. SUIT
No suit, action or proceeding for the recovery of any Claim under this endorsement shall be sustainable in any court of law or
equity unless the same be commenced within three (3) years after discovery by the Insured of the event which gives rise to the
Claim. The three(3)year period of time will be extended by the number of days between the date proof of loss was submitted and
the date the Claim is denied in whole or in part.
All other terms,conditions and exclusions of this policy remain unchanged.
Signed by: 10/6/2015
Date
Authorized Representative
U-VPL-155-A-NC(09/04)
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DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
Change Request Form
Insured Name: Dr. Claudia H.Sheppard Certificate No:VETPRO008742
If you would like to change your contact information or make a change to your current coverage, please indicate the correct
information and coverage selections below and sign form. Or, log in at www.avmaplit.com to update your certificate instantly.
Please see reverse for explanation of endorsements.
Mailing Address:
Number&Street City, County State, Zip
Office Phone: Alternate Phone:
Fax Number: E-mail:
I would prefer to receive important policy documents by: ❑ Email ['Mail
I am a(an): ❑ Employee ❑ Owner ❑Other
Professional Liability Coverage Please indicate your changes below and sign form. See reverse for details.
Species Type Primary Limits (per Excess Limits(per
Change to: occurrence/aggregate) occurrence/aggregate)
Change to: You must carry Primary Plan 3 to
❑ Predominantly equine purchase excess limits:
❑ Food animal or mixed practice ❑ Plan 1: $100,000/$300,000
❑ Predominantly small animal 111 Plan 2: $300,000/$900,000 111 Delete Excess Limits
❑ Plan 3: $1,000,000/$3,000,000
111 Plan 1: $1,000,000/$1,000,000
111 Small animal exclusive ❑ Plan 2: $2,000,000/$2,000,000
❑ Plan 3: $3,000,000/$3,000,000
❑ Plan 4: $4,000,000/$4,000,000
❑ Plan 5: $5,000,000/$5,000,000
Veterinary License Defense Coverage Please see reverse for details.
❑ ADD$100,000 limit($112 premium) ❑ DELETE
❑ ADD$50,000 limit($99 premium) By signing this form, you warrant that you have not had a regulatory
111 ADD$25,000 limit($85 premium) action taken against your license in the past 3 years and you are not
currently involved in a regulatory investigation.
Animal Bailee (Professional Extension) Coverage Only available practice owners,please see reverse for details.
Indicate the location address and plan desired for each location,or any necessary changes below and sign form.
1. Plan ['Add ❑ Change ['Delete
2. Plan ['Add ❑ Change ['Delete
3. Plan ['Add ❑ Change ['Delete
4. Plan ❑Add ❑ Change ❑Delete
Instantly update your certificate and pay your premium online at www.avmaplit.com, or return this form to our office by
mail or fax.All changes will be effective 12:01 am the date following receipt by our office or January 1st,whichever is later. If
you would like the above changes to your policy made sooner, please contact our office.
Signature of Insured: Date:
Insured's signature is required to process changes
AVMA PLIT• P.O. Box 1629, Chicago, IL 60690 • Phone 800-228-7548• Fax 888-754-8329 •www.avmaplit.com
DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B
AVMA PLIT Professional Liability Coverage Details
What is my species type?
Determine the species type that describes your professional liability practice from the options below
• Predominantly Equine: 70-100% of professional activity is devoted to equine practice
• Food Animal or Mixed Practice: 70-100% of professional activity is devoted to food animal practice OR
any combination in which no one animal type is 70%or more
• Predominantly Small Animal: 70-89% of professional activity is devoted to small animal practice
• Small Animal Exclusive: 90-100% of professional activity is devoted to small animal practice
Please Note: The Trust classifies wildlife, zoo, and fur bearing animals as small animal. Cervidae, poultry, and
ratites are classified as food animals. Please evaluate your classification accordingly.
What are Excess Limits?
For higher limits in addition to the primary limits, select an excess limit plan. You must have Primary Plan 3 to
qualify for excess limits.
What is Veterinary License Defense Coverage?
Legal fees to defend your veterinary license are not covered under the primary limit plan. License defense will
respond when you incur legal costs to defend your veterinary license if a complaint is filed with your state licensing
board. Select from the three limit options available to add this endorsement to your certificate.
Please note: This covers disciplinary issues that arise out of incidents that occur after the date coverage is secured.
If you have had a regulatory action taken against any veterinary license in the past three years, you must wait three
years from the date of the regulatory action to apply for this endorsement. A regulatory action means any formal
warning, restriction, probation, fine, penalty, suspension, or revocation of any veterinary license. A dismissed
complaint is not considered a regulatory action. If you are involved in an ongoing investigation, you are not eligible
for coverage. Please contact us when the outcome has been finalized to determine eligibility.
What is Animal Bailee (Professional Extension) Coverage?
The animal bailee endorsement covers damage to animals in your care or custody resulting from fire, wind, theft,
escape, flood, vandalism, attack from other animals, and other perils not related to treatment. If you hospitalize,
board, or transport animals, you could be held responsible for the injury, loss, or death of the animals.
This coverage is location-specific: a separate endorsement is needed for each practice location.
This coverage is only available to owners. Please make sure your ownership status is correctly noted on
the front side of this form.
Additional Questions? For more information about your coverage options and to see a complete list of premium
rates, please visit www.avmaplit.com or call the PLIT office at 800-228-7548, option 2.
All references to coverage are subject to the policy terms, limitations and exclusions.
AVMA PLIT• P.O. Box 1629, Chicago, IL 60690 • Phone 800-228-7548• Fax 888-754-8329 •www.avmaplit.com