AGENCY: LESTER KALMANSON AGENCY, INC
PO BOX 940008
MAITLAND, FL 32794-0008
PHONE: 407-645-5000 FAX: 407-645-2810 WWW.LKALMANSON.COM
PLEASE FILL OUT THIS FORM COMPLETELY - INCLUDE ALL NECESSARY CONTACT INFORMATION
1. DOG OWNER'S (INSURED'S) NAME:
2. MAILING ADDRESS:
CITY: STATE: ZIP:
3. PHONE: CELL:
WORK: FAX:
4. EMAIL:
5. NUMBER OF DOG (S) TO BE INSURED:
6. SEX OF DOG (S): Select MALE FEMALE BOTH <\SELECT>
7. BREED OF DOG (S):
8. AGE OF DOG (S):
9. TOTAL NUMBER OF DOG (S) / ANIMAL (S):
10. USE OF DOG(S):
11. ANY PRIOR INCIDENT (S) AND/OR CLAIM (S) / DOG BITE (S):
A) WITH A PERSON: Select YES NO <\SELECT> B) WITH ANOTHER ANIMAL: Select YES NO <\SELECT>
12. IF YES, PLEASE PROVIDE FULL DETAILS OF EACH INCIDENT:
13. PROVIDE THE LIMIT OF LIABILITY YOU REQUIRE:
PER OCCURENCE / PER (ANNUAL) AGGREGATE
14. ARE YOU AN INSURANCE AGENT / BROKER? Select YES NO <\SELECT>
IF YOU ARE AN INSURANCE AGENT / BROKER, PLEASE VISIT OUT "EXCESS AND SURPLUS" PAGE TO COMPLETE THE "NEW AGENT / BROKER" QUICK QUOTE ONLINE APPLICATION.
15. REMARKS (IF ANY):
