pets new format

8/11/2019 Pets New Format

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RefID ObjectType SourceID QuestionType ListCode ListOptionValue

1 Page

2 View

3 Question 10000001 Text



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BusClassTag BusClassId CarrierId LobId QuestionText/ListOptionDisplayValue

Your Company

Your Company

What is the zip code of your primary business location?

What's the name of your business?


3/73

Required ShowTitle Condition Notes Controller TipCode

no

8759001 - STR Pucks: Zip Code


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RefID ObjectType SourceID QuestionTy ListCode ListOptionV BusClassTag BusClassId

1 Page

2 View

3 Label

4 Question 260001 CheckBox






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CarrierId LobId QuestionText/ListOptionDisplayValue Required ShowTitle Condition

Your protection

Your protection no

What type of insurance do you need?

General Liability and Business Property

Umbrella (Excess Liability)

Commercial Auto Liability (Business owned autos)

Professional Liability / Errors and Omissions

Workers' Compensation / Employers' Liability


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Notes Controller TipCode

Hint

Language

Language

Language

Hint

Language


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RefID ObjectType SourceID QuestionType ListCode ListOptionV BusClassTag

1 Page

2 View

3 Label

4 Question 101001 Date

5 Label

6 Question 134001 Integer7 Question 135001 Integer

8 Label

9 Question 103005 Money



12 Label




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QuestionText/ListOptionDisplayValue

Business Basics

Business Basics

Company History

What date did your business begin?

Employees

How many people work for your business? (total staff, including yourself, owners, officers, employees, and contractors)Of these _ people, how many are owners or officers?

Revenue

What will your revenue be for the next fiscal year?

What is your revenue for the current fiscal year? (current revenue)

What was your revenue in the prior fiscal year? (prior revenue)

Annual Payroll

What is the total annual payroll for your entire office?

What is the annual payroll for owners and officers?


10/73

Required ShowTitle Condition Notes

no

If qid 134001 > 1

If Years in Bus from qID 101001 is >1

If Years in Bus from qID 101001 is >1

If qid 134001 > 1


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TipCode


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RefID ObjectType SourceID QuestionType ListCode

1 Page

2 View

3 Client's Property c.PrimaryContact.FirstName Text

4 Client's Property c.PrimaryContact.LastName Text

5 Client's Property c.PrimaryContact.EmailAddr Text

6 Client's Property c.PrimaryContact.PhoneNumber Text

7 Question 105001 Integer

8 Question N#247001 CheckBox

9 Client's Property c.PrincipalContact.FirstName Text

10 Client's Property c.PrincipalContact.LastName Text

11 Question 10028001 Radio List N#SoonStart

12

13

14


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Required ShowTitle Condition Notes

no

Default qID 247001 to 'Yes'

If no to qID 247001

If no to qID 247001


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Controller TipCode


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1 Page

2 View

3 Question 165001 Yes/No

4 Label

5 Label

6 Label7 Client's Property c.PrimaryAddress.Address1 Text

8 Client's Property c.PrimaryAddress.City Text

9 Client's Property c.PrimaryAddress.StateAbbr Text

10 Client's Property c.MailingAddress CheckBox

11 Client's Property c.PrimaryAddress.SqFeet Integer

12 Question c.PrimaryAddress.OwnRent Radio List RentOwn

13

14

15 Question c.PrimaryAddress.ConstType Radio List BuildingType

1617

18

19

20 Question c.PrimaryAddress.NumStores Integer


22 Label

23 Client's Property addr.PlumbingUpdateYear Year

24 Client's Property addr.WiringUpdateYear Year

25 Client's Property addr.RoofingUpdateYear Year

26 Client's Property addr.HeatingUpdateYear Year

27 Question addr.FireSprinkler Yes/No

28 Question addr Yes/No





33 Client's Property c.PrimaryAddress.UsePrimaryMailing CheckBox

34 Question ma.Address1 Text

35 Question ma.City Text

36 Question ma.StateAbbr State

37 Question ma.ZipCode Integer

38 Label


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39 Button

40 Label

42 Button

43 Client's Property c.addr Yes/No

44 Client's Property c.Addresses[n].Address1 Text

45 Client's Property c.Addresses[n].City Text46 Client's Property c.Addresses[n].StateAbbr State

47 Client's Property c.Addresses[n].ZipCode Integer

48 Client's Property c.addr Text

49 Client's Property c.addr Radio List RentOwn

50

51

52 Client's Property c.addr Radio List BuildingType

53

54

55

56

57 Client's Property c.addr Integer

58 Client's Property c.addr Year

59 Label

60 Client's Property addr.PlumbingUpdateYear Year

61 Client's Property addr.WiringUpdateYear Year

62 Client's Property addr.RoofingUpdateYear Year

63 Client's Property addr.HeatingUpdateYear Year








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ListOptionValue BusClassTag BusClassId CarrierId LobId

Own

Rent

GL, PROP, BOP

FRMNC

MY

FRM

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

PROP, BOP

PROP, BOP

PROP, BOP

PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP


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Own

Rent

GL, PROP, BOP

FR

MNC

MY

FRM GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

PROP, BOP

PROP, BOP

PROP, BOP

PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP

GL, PROP, BOP


20/73

QuestionText/ListOptionDisplayValue Required ShowTitle

Your Locations

Your Locations no

Is your business based in your home?

Primary Business Address

Home Address

We must have a physical address to provide a quote (not a P.O. Box).

Address:

City:

State:

Use this address as my mailing address

Square feet of space used for business at the address above:

Do you own or rent?

Own

Rent

Building construction is: (Place cursor over each item for a sample of each building

High rise building six stories or morelow rise building five stories or less with steel, glass and/or concrete construction

low rise brick or concrete block construction, typically built before 1970

low rise wood structure, may have brick exterior. Includes residential

Number of stories in this building:

Year the building was built:

Please state when updates were made to the following:

Plumbing _____

Wiring______

Roofing_____

Heating_____

Does the building have a fully protected and operational sprinkler system covering

100% of the building?

Do you have a Functioning and operational smoke and/or heat detectors in all units

Does the building have aluminum or knob & tube wiring?

Is all of the electrical wiring is connected to functioning and operational circuit

Is the building you occupy currently damaged by fire or otherwise?

Is the building partially constructed?

Use this address as my mailing address

Address:

City:

State:

Zip:

Other Business Addresses


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Add Another Location

Business Adderss #[n]

Remove Location

Is your business based in your home?

Address:

City:State:

Zip:

Square feet of space used for business at the address above:

Do you own or rent?

Own

Rent

Building construction is: (Place cursor over each item for a sample of each building

High rise building six stories or more

low rise building five stories or less with steel, glass and/or concrete construction

low rise brick or concrete block construction, typically built before 1970

low rise wood structure, may have brick exterior. Includes residential

Number of stories in this building:

Year the building was built:

Please state when updates were made to the following:

Plumbing _____

Wiring______

Roofing_____

Heating_____

Does the building have a fully protected and operational sprinkler system covering

Do you have a Functioning and operational smoke and/or heat detectors in all units

Does the building have aluminum or knob & tube wiring?

Is all of the electrical wiring is connected to functioning and operational circuit

Is the building you occupy currently damaged by fire or otherwise?

Is the building partially constructed?


22/73

Condition Notes Controller

If No to qID 165001

If NO to qID 165001

Default to "Yes"

If QID 171001 older 25 years





If qID 171001 > 1978

If qID 171001 > 1978

If No to qID 165001 Own selected

If No to qID 165001 Own selected

If 'No' to Use this address as my mailing address (

If 'No' to Use this address as my

mailing address (qID






23/73

If 'Add Another Location' is selected




If 'Add Another Location' is selectedIf 'Add Another Location' is selected





If 'Add Another Location' is selected qID






If qID 171001 > 1978

If qID 171001 > 1978


24/73

TipCode

HighRiseLowRiseSteel

LowRiseBrick

LowRiseWood

qID c.MailingAddress)


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1 Page

2 View

3 Question 269001 DropDown List GLCoverageAmount

4

5

6 Label


8 Question 3033001 DropDown List GL_EPLAmount

9

10

11

12

13

14

15


17 Label



20 Question 3099001 DropDown List GL_EPLI_Prior_Limit_Hartford

21

22

23

24

25

26

27

28





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36 Question 3107001 CheckBox List EPL_EmploymentPolicie

37

38

39

40

42 Question 3108001 CheckBox List EPL_EmploymentPolicie

43

44

45

46

47 Label


49 Question 3035001 DropDown List GL_DataBreachResponseExpenses

5051

52

53

54 Question 3036001 DropDown List GL_DataBreachDefenseLiability

55


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56

57

58

59 Question 3087001 CheckBox List DataBreach_TypesOfClient

60

61

62

63

64

65

66

67

68

69 Question 3088001 CheckBox List DataBreach_ComputerSystemsProte

ction

70

71

72

73

74

75 Question 3089001 CheckBox List DataBreach_PoliciesInplace

76

77

78

79

80

81 Question 3090001 CheckBox List DataBreach_TypesOfEquipment

82

83

84

85


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86

87


90 Question 3092001 CheckBox List DataBreach_ProtectPersonallyIdentif

iable

91

92

93

94

95

96 Question 3093001 CheckBox List DataBreach_CreditCardsType

97

9899

100

101


103 Question 3095001 CheckBox List DataBreach_CardInfPurged

104

105

106

107

108



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110 Label

111 Question 1102001 DropDown List BOPCoverageAmount

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128129

130

131

132 Question 8107001 DropDown List OADeductible

133

134

135

136

137

138

139 Label

140 Label


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141 Question 1120001 DropDown List OfficeCoverage_Computers

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159

160

161

162 Label

163 Question 10225001 CheckBox List MedEquipType

164

165

166

167

168


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169

170 Question 10226001 DropDown List CTScans

171

172

173

174

175

176

177 Question 10227001 DropDown List CTScansGEModel

178

179

180

181

182

183

184 Question 10228001 DropDown List CTScansNeuroModel

185

186

187

188

189

190 Question 10229001 DropDown List CTScansPhilipsModel

191

192

193

194

195

196 Question 10230001 DropDown List CTScansSiemensModel

197

198

199

200

201

202

203 Question 10231001 DropDown List CTScansToshibaModel


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204

205

206

207

208

209 Question 10232001 DropDown List NumberSlices

210

211

212

213

214


216 Question 10234001 DropDown List ManufMRI

217

218

219

220

221

222

223 Question 10235001 DropDown List GEMRI

224

225

226

227

228

229

230 Question 10236001 DropDown List HitachiMRI

231

232

233 Question 10237001 DropDown List PhilipsMRI

234

235

236

237

238 Question 10238001 DropDown List SiemensMRI


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239

240

241

242 Question 10239001 DropDown List ToshibaMRI

243

244

245 Question 10239001 DropDown List MagnetPower

246

247

248

249




253 Question 10244001 CheckBox List MedEquipApply

254

255

256

257

258

259

260

261


263 Label




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268 Label

269 Question 273001 DropDown List AutoPersonalHowOften

270

271


273 Question 1123001 Radio List AutoPersonalRadiusOfOperation

274

275

276

277 Question 1124001 CheckBox List AutoPersonalEmployeesInvolvedIn

278

279

280

281

282

283



286 Label

287 Question 272001 DropDown List HowOftenRented

288

289

290

291

292293 Question 1127001 CheckBox List AutoPersonalControlMeasures

294

295


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296

297 Label

298 Question 507001 DropDown List UM_Liability_Coverage

299

300

301

302

303

304 Label







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311 Question 3019001 CheckBox List AlliedHealth_StorageContainers

312

313

314








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ListOptionValue BusClassTag BusClassId CarrierId LobId

67

67

67

1000000|2000000 67

2000000|4000000 67

67

67

67 100. 108 GL, BOP

10000

25000

50000

100000

250000

500000

1000000

67

67 100. 108 GL, BOP

67 100. 108 GL, BOP

67 100. 108 GL, BOP

67 100. 108 GL, BOP

25000|25000

50000|50000

100000|100000

100000|200000

250000|250000

500000|500000

1000000|1000000

Other

67 100. 108 GL, BOP

67 100. 108 GL, BOP

67 100. 108 GL, BOP


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67 100. 108 GL, BOP

67 100. 108 GL, BOP

67 100. 108 GL, BOP

67 100. 108 GL, BOP

67 100. 108 GL, BOP

EmploymentApplication

EmploymentAtWill

HRpolicies

None

67 100. 108 GL, BOP

TrackingClaim

PerformanceEvaluations

TerminationsByHR

None

67 100 GL, BOP

67 100 GL, BOP

67 100 GL, BOP

1000025000

50000

100000

67 100 GL, BOP

50000


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100000

250000

500000

67 100 GL, BOP

CreditCardNumbers

SSN

DOB

DriversLicenseNumbers

MedicalData

LegalData

FinancialData

Email

None

67 100 GL, BOP

Password GL, BOP

Firewalls GL, BOP

Antivirus GL, BOP

DataSecurityByVendor GL, BOP

None GL, BOP

67 100 GL, BOP

CriminalBackgroundCheck GL, BOP

WrittenPolicy GL, BOP

AccessDBJob GL, BOP

RestrictedAccess GL, BOP

None GL, BOP

67 100 GL, BOP

SmartPhones

ExHDD

ThumbDrive

Laptop


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Tablet

None

67 100 GL, BOP

67 100 GL, BOP

PasswordProtection

Encryption

Fingerprint

DataErasure

None

67 100 GL, BOP

AmericanExpress

DiscoverMasterCard

Visa

Other

67 100 GL, BOP

67 100 GL, BOP

AfterTransactiond

OneMonth

SixMonths

AfterSixMonths

NotApply

110, 200


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110, 200

1000

5000

10000

20000

25000

30000

40000

50000

60000

70000

80000

90000

100000

125000

150000

175000

200000300000

400000

500000

110, 200

250

500

1000

2500

5000

10000

110, 200

110, 200


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110, 200

10000 110, 200

15000 110, 200

25000 110, 200

50000 110, 200

75000 110, 200

100000 110, 200

125000 110, 200

150000 110, 200

200000 110, 200

250000 110, 200

275000 110, 200

300000 110, 200

325000 110, 200

350000 110, 200

375000 110, 200

400000 110, 200

425000 110, 200

450000 110, 200

475000 110, 200

500000 110, 200

110, 200

67 303, 906 110, 200

CTScans

CAT Scans

MRI

LinearAcceleratorsRadiationT

herapy

Lithotripters


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None

67 303, 906 110, 200

Unknown 110, 200

GeneralElectric 110, 200

Neurologica 110, 200

Philips 110, 200

Siemens 110, 200

Toshiba 110, 200

67 303, 906 110, 200

Unknown 110, 200

AllModels 110, 200

Brightspeed 110, 200

Discovery 110, 200

LightSpeed 110, 200

Optima 110, 200

67 303, 906 110, 200

Unknown 110, 200

AllModels 110, 200

BodyTomCore 110, 200

CereTomCore 110, 200

CereTomOTOScanCore 110, 200

67 303, 906 110, 200

Unknown 110, 200

AllModels 110, 200

Brilliance 110, 200

Ingenuity 110, 200

MX 110, 200

67 303, 906 110, 200

Unknown 110, 200

AllModels 110, 200

DefinitionAS 110, 200

DefinitionFlash 110, 200

Emotion 110, 200

Spirit 110, 200

67 303, 906 110, 200


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Unknown 110, 200

AllModels 110, 200

Aquilion 110, 200

Definition 110, 200

Emotion 110, 200

67 303, 906 110, 200

Unknown 110, 200

2-8 110, 200

16-20 110, 200

32-64 110, 200

128-320 110, 200

67 303, 906 110, 200

67 303, 906 110, 200

Unknown 110, 200

GeneralElectric 110, 200

Hitachi 110, 200

Philips 110, 200

Siemens 110, 200

Toshiba 110, 200

67 303, 906 110, 200

Unknown 110, 200

AllModels 110, 200

Discovery 110, 200

Optima 110, 200

SignaHD 110, 200

SignaVibrant 110, 200

67 303, 906 110, 200

Unknown 110, 200

Echelon 110, 200

67 303, 906 110, 200

Unknown 110, 200

AllModels 110, 200

Achieva 110, 200

Ingenia 110, 200

67 303, 906 110, 200


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Unknown 110, 200

AllModels 110, 200

Magnetum 110, 200

67 303, 906 110, 200

Unknown 110, 200

Vantage 110, 200

67 303, 906 110, 200

Unknown

1_0_Tesla

1_5_Tesla

3_0_Tesla

67 303, 906 110, 200

67 303, 906 110, 200

67 303, 906 110, 200

67 303, 906 110, 200

UPS

SurgeProtection

FullMaint

PurchasedUsedRefurbished

GreaterThan10yo

ProtectedFSS

SmokeDetectors

None

100, 200

100, 200

100, 200

100, 200


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100, 200

100, 200

100, 200

100, 200

0-3

3+

100, 200

100, 200

0|50

51|200

200+

100, 200

Delivery

OutsideSales

RoutineErrands

TimeConstraints

StudentTransportation

Other

100, 200

100, 200

100, 200

100, 200

OCCASIONALTRAVEL

LESSTHANONCEPERWEEK

SEVERALTIMESPERWEEK

Other

None100, 200

PersonalAutoLimits

MvrOnFile


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MaintainMinLimits

1000000|1000000

2000000|2000000

3000000|3000000

4000000|4000000

5000000|5000000

100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,200


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67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

S1

S2

None

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200

67 303, 448, 906 100 100, 110,

200


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QuestionText/ListOptionDisplayValue Required ShowTitle Condition

General Liability & Property Policy

General Liability & Property Policy no

Please indicate the amount of general liability

coverage you require:

$1,000,000/$2,000,000

$2,000,000/$4,000,000

Employment Practices Liability

Do you want your quote to include coverage for

Employment Practices Liability? (Coverage to

respond to allegations such as discrimination,

wrongful termination or sexual harassment of

employees.)

Please indicate the amount of Employment

Practicies Liability coverage you require:

if qid 3032001 = yes

$10,000 (Built-In)

$25,000

$50,000

$100,000

$250,000

$500,000

$1,000,000

Do you currently carry Employment Practices

Liability (EPLI) coverage?


Please provide the following regarding your

current EPLI coverage:


Policy Effective Date: if qid 3096001 = yes

Insurance Carrier: if qid 3096001 = yes

Limit of EPLI coverage: if qid 3096001 = yes

$25,000 / $25,000

$50,000 / $50,000

$100,000 / $1000

$100/000 / $200,000

$250,000 / $250,000

$500,000 / $500,000

$1,000,000 / $1,000,000

Other Limit

EPLI Retroactive Date: if qid 3096001 = yes

Have you maIntegerained continuous EPLI coverage

from the Retroactive Date above to the present?


Have you had a workforce reduction of greater than

25% in any 2 of the past 3 years?



50/73

Do the insured anticipate a workforce reduction of

greater than 25% in the next year?


Do greater than 25% of your employee's have salary

equal to or greater than $100,000?


How many employment related claims,

administrative proceedings, EEOC action letters or

attorney letters have you experienced in the pastthree years?:


Is any person proposed for coverage aware of any

fact or circumstance or any actual or alleged act,

error or omission which might give rise to a claim

that would fall within the scope of the proposed

coverage?


Please indicate which of the following written

employment related policies are in place and easily

accessible for all employees to reference:


A written employment application

An employment-at-will statement

An employee handbook or HR policies/procedures

None of the Above

Please indicate which of the following written

employment related policies are in place and easily

accessible for all employees to reference:


A written procedure for reporting and tracking claim

and incident information is in place

Regular written performance evaluations of all

employees are conducted

Requires all terminations to be reviewed by Human Resources or Legal Counsel

None of the above

Data Breach

Do you want your quote to include Data Breach

coverage?(Provides coverage for loss cause by a

breach of personally identifiable information)

Data Breach - Response Expenses (such as

notification expenses, crisis management expenses,

monitoring services, good faith advertising, and

legal/forensic services)


$10,000$25,000

$50,000

$100,000

Data Breach - Defense & Liability (coverage for civil

awards, settlements and judgments as a result of a

Data Breach claim that you are legally obligated to

pay)


$50,000


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$100,000

$250,000

$500,000

Which of the following types of client/customer

information do you store electronically or in files,

process or transmit?


Credit or debit card numbers

Social security numbers

Date of birth

Drivers license numbers

Client medical data/records

Client legal data/records

Client financial data/records

Email addresses

None of the above

Which of the following do you have in place on all

of your computer systems e.g. servers, laptops,

networks unless otherwise noted?

qID 3087001 is anything EXCEPT

None

Password protection

Firewalls

Antivirus Software

Computer network data security functions are

performed by an outside vendor.

None of the above

Which of the following procedures/policies do you

have in place?

if qid 3087001 =MedicalData,

LegalData, FinancialData

Criminal employee background check at hiring

Written Privacy policy

Access to data based on job function

Immediate restricted access to data upon employee

termination

None of the Above

Which of the following procedures/policies do you

have in place?

if qid 3087001 =MedicalData,

LegalData, FinancialData

iPhone, BlackBerry, or other Smart Phones

External hard drive

Thumb drive

Laptop


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iPad or Tablet type device

None of the above

Do you store, process, transfer or transmit

personally identifiable information such as social

security numbers, credit or debit card info, client

legal, medical or financial information on these

mobile devices or equipment?

qID 3090001 is anything EXCEPT

None

Which of the following steps has the insured taken

to protect personally identifiable information on

these devices or equipment?

If qID 3090001 = yes

Implemented use of passcode/password protection

Implemented encryption of files and emails on all

equipmentsFingerprInteger access required

Data erasure enabled

None of the above

Which of the following credit or debit cards is your

payment processing equipment authorized to

rocess transactions for?American Express

DiscoverMasterCard

Visa

Other

Please describe other credit or debit cards, and

provide the names of the insured's payment card

rocessin com anies.How often is credit or debit card information

purged from your systems?

Immediately after transaction is processed

Within one month of transaction

Within six months of transaction

Some or all information is retained for more than six

Does not apply as no electronic cardholder data

storage

Check here to decline coverage for your computers

and other office contents. (Note: When your policy


53/73

Office Address If qID 506001 = Yes

Office contents coverage:(Coverage for your

business personal property such as furniture, desks,chairs, and office supplies, that are primarily used in

our business.$1,000

$5,000

$10,000

$20,000

$25,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

$125,000

$150,000

$175,000

$200,000$300,000

$400,000

$500,000

Deductible If qID 506001 = Yes

$250

$500

$1,000

$2,500

$5,000

$10,000

Optional Coverage: Select the coverage options

you are Integererested in below: (Please select all

that a l

If qID 506001 = Yes

Please provide the dollar amount required to

completely replace each property listed below.

These figures should represent the amount required

If qID 506001 = Yes


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Computers & Media (including PC's, peripherals,

software, etc.)

If qID 506001 = Yes

$10,000

$15,000

$25,000

$50,000

$75,000

$100,000

$125,000

$150,000

$200,000

$250,000

$275,000

$300,000

$325,000

$350,000

$375,000

$400,000

$425,000

$450,000

$475,000

$500,000

Medical Equipment

Which of following types of medical equipment does

the facility have? (Check all that apply)

If qID 506001 = yes

Computerized Tomography Scanners (CT Scans)

Computerized Axial Tomography Scanners (CAT

Scans)

Magnetic Resonance Imaging Scanners (MRI)

Linear Accelerators or any other external bean of

radiation therapy

Lithotripters


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None of the above

Select Manufacturer of Computerized Tomography

Scanners (CT Scans):

if qid 10225001 = CTScans

Unknown

General Electric

Neurologica

Philips

Siemens

Toshiba

Select General Electric Model of Computerized

Tomography Scanners (CT Scans):

if qid 10226001 = GeneralElectric

Unknown

All Models

Brightspeed

Discovery

LightSpeed

Optima if qid 10226001 = CTScans

Select Neurologica Model of Computerized

Tomography Scanners (CT Scans):

if qid 10226001 = Neurologica

Unknown

All Models

BodyTom Core

CereTom Core

CereTom OTOScan Core

Select Neurologica Model of Computerized

Tomo ra h Scanners CT Scans :

if qid 10226001 = Philips

Unknown

All Models

Brilliance

Ingenuity

MX

Select Siemens Model of Computerized Tomography


if qid 10226001 = Siemens

Unknown

All Models

Definition AS

Definition Flash

Emotion

Spirit

Select Siemens Model of Computerized Tomography


if qid 10226001 = Toshiba


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Unknown

All Models

Aquilion

Definition

Emotion

Select Number of Slices of ComputerizedTomography Scanners (CT Scans): if qid 10226001 = CTScans

Unknown

2-8

16-20

32-64

128-320

Describe the Computerized Tomography Scanners

CT Scans :

if qid 10225001 = CTScans

Select Manufacturer of Magnetic Resonance

Imaging Scanners (MRI):

if qid 10225001 = MRI

Unknown

General Electric

Hitachi

Philips

Siemens

Toshiba

Select General Electric Model of Magnetic

Resonance Imaging Scanners (MRI):

if qid 10234001 = GeneralElectric

Unknown

All Models

Discovery

Optima

Signa HD

Signa Vibrant

Select General Electric Model of Magnetic

Resonance Imaging Scanners (MRI):

if qid 10234001 = Hitachi

Unknown

Echelon

Select Phillips Model of Magnetic Resonance


if qid 10234001 = Philips

Unknown

All Models

Achieva

Ingenia

Select Siemens Model of Magnetic Resonance


if qid 10234001 = Siemens


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Unknown

All Models

Magnetum

Select Toshiba Model of Magnetic Resonance


if qid 10234001 = Toshiba

Unknown

Vantage

Select Magnet Power of Magnetic Resonance

Ima in Scanners MRI :

if qid 10225001 = MRI

Unknown

< 1.0 Tesla

1.5 Tesla

3.0 Tesla

Describe the Magnetic Resonance Imaging Scanners

(MRI):

if qid 10225001 = MRI

Provide the details of medical equipment selected: If qid 10225001 = Linear, Lithotrupt

Is any of this medical equipment (CT Scans, CAT

scans, MRIs, Linear Accelerators or Lithotripters)

normally moved to other locations using a vehicle or

If qid 10225001 = Linear, Lithotrupt

Which of the following apply to CT Scans, CAT Scans,

MRIs, Linear Accelerators, or Lithotripters? (Check

all that apply)

If qid 10225001 = Linear, Lithotrupt

UnIntegererrupted power supply (UPS)

Surge Protection

Full maIntegerenance contract (not just Time and

Material contract)

Purchased used/refurbished

Greater than 10 years old

Protected by an automatic fire suppression system

Smoke/Heat detectors

None of the above

Does your facility follow the American College of

Radio Listlogy (ACR) Safe MR Practices?

if qid 10225001 = MRI

Auto Liability

Do you have any vehicles commercially owned/titled to your business?

Would you like a quote for Commercial Auto coverage? If qID 270001 = yes


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Do you want your quote to include coverage for Hired/Non-Owned Auto Liability? If qID 270001 = no

Do you have a commercial auto policy in force? If qID 576001 = yes

Personal Vehicles Used in Business

How often do your employees use their personal

vehicle on company business?

If qID 576001 = yes

Occasionally

More than 3 times a week

How many of your employees regularly (more than If qID 273001 = '+3'

What is the maximum radius of operation? If qid 1122001 > 0

Local (0 to 50 miles)

Integerermediate (51 to 200 miles)

Long distance (more than 200 miles)

Employees who drive are involved in (please check If qID 576001 = yes

Delivery

Outside Sales

Routine Errands

Time ConstraIntegers

Student or Youth Transportation

Other

Please Describe 'Other' If qid 1124001 = 'Other'

How many of the employees regularly using their If qID 576001 = yes

Rented Vehicles Used in Business

How often do you or your employees rent vehicles

Occasional out of town travel

Less than once per week

Several times per week

Other

None of the AbovePlease indicate the control measures in place (Check

Employees carry personal auto insurance liability

limits of at least 100/300/50

Drivers' MVRs are on file and checked annually by

insured


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Require all employees & volunteers who operate

their personal autos on behalf of your organization

Umbrella Liability

Please indicate the amount of umbrella liability

coverage you require:

If qID 261001 = yes

$1,000,000/$1,000,000

$2,000,000/$2,000,000

$3,000,000/$3,000,000

$4,000,000/$4,000,000

$5,000,000/$5,000,000

Hazardous Material/Waste Management

Has there been a discharge, dispersal or release of a

hazardous or regulated material or waste to air,

land or water from your location since you've

owned or occupied it or prior to your ownership or

occu anc ?Has there been a discharge, dispersal or release of a

hazardous or regulated material or waste to air,

land or water at any off premises locations due to

your operations.

Is your firm required under any federal or state

statute or regulation (e.g. SARA Title III), to report or

disclose the presence of one or more hazardous

materials?

Is your site or your operation in any form of

environmental remediation?

Is your firm required, under any federal or statestatute or regulation, to report or permit the

storage, discharge, treatment, or disposal of any

hazardous waste in any form, including but not

limited to solid wastes, liquid wastes and air quality


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Do you have any chemical, flammable or other

hazardous material (solid or liquid) on your

location?

Indicate which of the following storage containers

are utilized:

If qid 3018001 = yes

Above ground storage tanks

Underground storage tanks

None of the Above

Provide the age of the oldest above ground storage

tank(s).

If qid 3019001 = S1

Provide the total gallon capacity of all the above

ground storage tanks.

If qid 3019001 = S1

What is the construction of the above ground

storage tank?

If qid 3019001 = S1

Provide a description of the contents. If qid 3019001 = S1

Do you or others have hazardous materials stored,

in any form or manner, in or adjacent to your

business, in quantities that would exceed the

Threshold Planning Quantity of the US

Environmental Protection A enc 40 CFR 355 etAre you aware of any claims or suits or potential

claims or suits regarding exposure to toxicsubstances?


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Notes Controller TipCode

New List Code and List


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Default to TRUE


66/73

If WebBusClass = 'Animal Hospital (27001)' or 'Veterinarian (27006)

UpDate ListCode Value

from E1 to value


from E2 to value


from E3 to value


from E4 to value


from E5 to value


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from E6 to value


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ers, CAT

ers, CAT, MRI, 'CT Scan'

ers, CAT, MRI, 'CT Scan'

If BOP/GL/HNOA selected


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If 'Animal Hospital

(27001)', 'Kennel (27002)'

or 'Veterinarians (27006)'

AND Primary State = IN,

LA or VT

If 'Animal Hospital

(27001)', 'Kennel (27002)'



LA or VTIf 'Animal Hospital

(27001)', 'Kennel (27002)'




(27001)', 'Kennel (27002)'



LA or VT

If 'Animal Hospital

(27001)', 'Kennel (27002)'



LA or VT

If 'Animal Hospital(27001)', 'Kennel (27002)'



LA or VT


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If 'Animal Hospital

(27001)', 'Kennel (27002)'



LA or VT

If 'Animal Hospital

(27001)', 'Kennel (27002)'




(27001)', 'Kennel (27002)'or 'Veterinarians (27006)'


LA or VT


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ObjectTypeList: QuestionTypeList: YesNoList

Page Radio List yes

View Yes/No no

Question Yes/No/NA

Label Text

Service MultiTextIndustry CheckBox

Button CheckBox List

Client's Property DropDown List

Integer

Money

Percent

Date

Phone

SSN

ZipCode

State

Year

pets new format

Documents