OVMA Insurance Program Application Please enable JavaScript in your browser to complete this form.Basic Information - Step 1 of 6Insured Name: *Legal Entity (C-Corp, LLC, LLP, Other):Tax ID: *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact First & Last Name: *Email: *Phone: *Number of Years in Business:Additional Locations:Current Carrier & Renewal Date: *Years with Current Carrier:NextBuilding Value: $ *Contents: $Deductible:$500$1,000$2,500Building Construction:FrameJoisted MasonryNon-CombustibleMasonry Non-CombustibleOtherRoof Material:Built-Up Tart and GravelCompositionConcrete TileMetalRockClayRolledOtherYear Built: *Year Roof was last Updated:Year Wiring was last Updated:Year Plumbing was last Updated:Year HVAC was last Updated:Number of Stories:Sprinklered %Square Footage:Protection Class Code:Additional Insured/Certificate Holder:Name of Additional Insured/Certificate Holder:Address of Additional Insured/Certificate Holder:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextGross Annual Receipts: $Number of Veterinarians:Are all Vets associated with practice licensed? If not, how many are not?Number of Technicians:How would you describe your practice?Small - animal practiceMixed, predominantly small-animal practiceFood animal/Livestock practiceEquine PracticeAdditional Insured Type:Managers or Lessor's of PremisesVendorsControlling InterestsDesignated Person or OrganizationMortgageeAssigneeReceiverAdditional Insured Name:Additional Insured Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextHave there been any losses in the past 3 years? If so, please explain:Mobile Equipment Amount?: $Any Transportation of Animals?In the past 3 years, has any license investigation or action been taken against you or an employee? If yes, please provide name(s), date(s), and explain:Are any services provided to animals in zoos, circuses, carnivals, rodeos, theatrical or other show enterprises?Are any of the following operations performed?Training or obedience schoolsCommercial cattle/hog confinement operationsPrize LivestockBreeding of laboratory animalsAnimal AuctionsIf yes, please explain:NextAre there any Business Owned Autos?If yes, please provide the following for each vehicle used: Year, Make, Model, VIN#Driver Information: Name, Date of Birth, Drivers License #, Use (Personal/Commercial)Limits: Bodily Injury -Limits: Property Damage -Deductibles: Comprehensive - Deductibles: Collision - NextVeterinarians, Technicians, Drivers: # of Employees at Each LocationVeterinarians, Technicians, Drivers: Annual PayrollClerical: # of Employees at Each LocationClerical: Annual PayrollEmployers Liability Limits$500,000/$500,000/$500,000$1,000,000/$1,000,000/$1,000,000OwnersIncludedExcludedIf Excluded, provide: Name, Annual Payroll, % of Ownership, and DutiesCaptcha * = Submit Contact Get In Touch (972) 720-5340 | info@TexCapINS.com 12404 Park Central Dr. Suite 200-N, Dallas, TX 75251 Name Email Address Message 13 + 1 = Submit TexCap Insurance Guiding you to a more secure future. FollowFollowFollowFollow Privacy & Cookies Policy Disclaimer Leave us a Review ©2022 TexCap Insurance. All Rights. Site Browse a Page Home Property & Casualty Employee Benefits Private Client Individuals & Families Life Insurance Small Business Veterinary Programs Blog Contact Get In Touch info@TexCapINS.com (972) 720-5340 M-F: 8:30am - 4:30pm 12404 Park Central Drive Suite 200-N Dallas, Texas 75251
