Insurance Kennel Application

INSURANCE KENNEL APPLICATION

Applicant Information

Contact Person:    Phone:    Email:

Federal Tax ID / EIN:    State of Operation:    Kennel License Number:

License Issuing Authority:    License Expiration:

Date Business Established:    Years in Business:    Maximum Licensed Capacity:

Ownership and Entity

Entity Type: Individual Partnership Corporation LLC Nonprofit Other

Animals and Operations

Types of Animals Housed: Dogs Cats Exotic Livestock Other:

Average Number on Premises:    Peak Season Number:

Boarding Daycare Grooming Training Breeding Retail Sales Adoption / Rescue Transportation of Animals Shows / Events

Facility Protection & Protocols

Fire Protection: Sprinklers: Yes    Smoke Detectors: Yes    Fire Extinguishers: Yes

Insurance Requested / Policy Details

Desired Effective Date:    Policy Period Requested (From):    To:

Coverage Options and Limits (select applicable coverages and indicate limit and deductible)

General Liability    Limit: $    Deductible: $

Animal Bailee Liability    Limit: $    Deductible: $

Mortality / Live Animal Coverage    Limit per animal: $    Deductible: $

Property / Building    Limit: $    Deductible: $

Loss of Income / Business Interruption    Limit: $    Waiting Period (days):

Employee Dishonesty / Crime    Limit: $

Estimated Annual Premium: $    Preferred Payment Plan: Annual Semi-Annual Monthly

Prior Insurance & Loss History

Yes No

Beneficiary Designation (For Mortality Proceeds)

Relationship:    Percentage:

Relationship:    Percentage:

Attachments Checklist

Please indicate which documents are attached with this application: Vaccination records / intake forms Current facility photos (interior and exterior) Lease or deed Operations manual / protocols Employee list and background-check confirmation

Declarations, Authorizations & Notices

The undersigned applicant declares that the information provided in this application is true, complete and correct to the best of applicant's knowledge and that no material fact has been misstated or omitted. Applicant understands that this application, including any attachments, will be relied upon by the insurer in determining eligibility, coverage terms and premiums. A material misrepresentation, omission or failure to disclose information may result in denial of coverage or rescission of any policy issued.

Applicant authorizes the insurer and its representatives to inspect the premises, records and animals as reasonably necessary for underwriting and claim investigation purposes. Applicant acknowledges that any inspection does not warrant or guarantee the safety of the premises or animals and does not impose liability on the inspector or insurer for conditions not reasonably discoverable at time of inspection.

The following matters are expressly excluded from coverage unless specifically endorsed: intentional acts by the insured, damages arising from war or nuclear hazard, pollution or environmental contamination, and losses arising from unlawful or non-routine breeding practices. Specific exclusions and endorsements applicable to any policy will be set forth in the policy form and endorsements issued by the insurer.

Applicant certifies that to the best of their knowledge there is not currently an outbreak of any communicable animal disease at the facility, and that all animals taken into custody will have required vaccinations and health checks as described in the vaccination protocol section of this application.

Certification and Signature

By signing below, the undersigned certifies that they are authorized to bind the applicant to the representations and statements contained in this application, and that they understand and agree that coverage will be effective only upon issuance of a policy by the insurer. The undersigned acknowledges that any false statement or concealment of fact may constitute fraud and may void any policy issued in reliance on this application.

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