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DocuSign Envelope ID:2A1EB275-A6CB-484A-ABD4-C1F2E7C54E2B <br /> Change Request Form <br /> Insured Name: Dr. Claudia H.Sheppard Certificate No:VETPRO008742 <br /> If you would like to change your contact information or make a change to your current coverage, please indicate the correct <br /> information and coverage selections below and sign form. Or, log in at www.avmaplit.com to update your certificate instantly. <br /> Please see reverse for explanation of endorsements. <br /> Mailing Address: <br /> Number&Street City, County State, Zip <br /> Office Phone: Alternate Phone: <br /> Fax Number: E-mail: <br /> I would prefer to receive important policy documents by: ❑ Email ['Mail <br /> I am a(an): ❑ Employee ❑ Owner ❑Other <br /> Professional Liability Coverage Please indicate your changes below and sign form. See reverse for details. <br /> Species Type Primary Limits (per Excess Limits(per <br /> Change to: occurrence/aggregate) occurrence/aggregate) <br /> Change to: You must carry Primary Plan 3 to <br /> ❑ Predominantly equine purchase excess limits: <br /> ❑ Food animal or mixed practice ❑ Plan 1: $100,000/$300,000 <br /> ❑ Predominantly small animal 111 Plan 2: $300,000/$900,000 111 Delete Excess Limits <br /> ❑ Plan 3: $1,000,000/$3,000,000 <br /> 111 Plan 1: $1,000,000/$1,000,000 <br /> 111 Small animal exclusive ❑ Plan 2: $2,000,000/$2,000,000 <br /> ❑ Plan 3: $3,000,000/$3,000,000 <br /> ❑ Plan 4: $4,000,000/$4,000,000 <br /> ❑ Plan 5: $5,000,000/$5,000,000 <br /> Veterinary License Defense Coverage Please see reverse for details. <br /> ❑ ADD$100,000 limit($112 premium) ❑ DELETE <br /> ❑ ADD$50,000 limit($99 premium) By signing this form, you warrant that you have not had a regulatory <br /> 111 ADD$25,000 limit($85 premium) action taken against your license in the past 3 years and you are not <br /> currently involved in a regulatory investigation. <br /> Animal Bailee (Professional Extension) Coverage Only available practice owners,please see reverse for details. <br /> Indicate the location address and plan desired for each location,or any necessary changes below and sign form. <br /> 1. Plan ['Add ❑ Change ['Delete <br /> 2. Plan ['Add ❑ Change ['Delete <br /> 3. Plan ['Add ❑ Change ['Delete <br /> 4. Plan ❑Add ❑ Change ❑Delete <br /> Instantly update your certificate and pay your premium online at www.avmaplit.com, or return this form to our office by <br /> 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 <br /> you would like the above changes to your policy made sooner, please contact our office. <br /> Signature of Insured: Date: <br /> Insured's signature is required to process changes <br /> AVMA PLIT• P.O. Box 1629, Chicago, IL 60690 • Phone 800-228-7548• Fax 888-754-8329 •www.avmaplit.com <br />