PET INSURANCE PARTICIPATION AGREEMENT

Clinic is indicating its intent to participate in the Pet Insurance Recommended Supplier Initiative developed by the providers of ASPCA® Pet Health Insurance and PSIvet®

Clinic agrees to:

- Complete an educational staff “Lunch and Learn” developed and presented by Supplier
- Agree to prominently display ASPCA® Pet Health Insurance materials within the hospital waiting room and/or exam room.
- Select a Lease Option below and complete all items listed within the quarter with materials provided by Supplier.

Lease Option(Required)

Level 1 - $100/Quarter

Level 2 - $200/Quarter

Level 3 - $300/Quarter

Access Fee - $500

This is to certify that Clinic is a PSIvet® member, and the ASPCA® Pet Health Insurance program materials will be prominently displayed in the Clinic physical or on-line space according to the Lease Option selected.

Clinic Name(Required)

PSIvet Member Number(Required)

Email(Required)

Phone

Signature(Required)

Print Name(Required)

Date(Required)

Questions regarding the ASPCA® Pet Health Insurance plans or participation in the ASPCA® Pet Health Insurance / PSIvet program can be directed to 877-738-2677 or vets@aspcapetinsurance.com.

The ASPCA® is not an insurer and is not engaged in the business of insurance. Products are underwritten by United States Fire Insurance Company (NAIC #21113. Morristown, NJ). Insurance products are produced and administered by C&F Insurance Agency, Inc. (NPN # 3974227), a Crum & Forster company. Through a licensing agreement, the ASPCA® receives a royalty fee that is in exchange for use of the ASPCA®’s marks and is not a charitable contribution. C&F and Crum & Forster are registered trademarks of United States Fire Insurance Company.