lkalmanson - Commercial Canine Liability

LIABILITY COVERAGE WILL BE RESTRICTED TO THE DIRECT BODILY INJURY / PROPERTY DAMAGE CAUSED BY THE OWNED SCHEDULED CANINE ( S ) ONLY

AGENCY: LESTER KALMANSON AGENCY, INC &/OR MITCHEL KALMANSON

PO BOX 940008
MAITLAND, FL 32794-0008
PHONE: 407-645-5000
FAX: 407-645-2810
WWW.LKALMANSON.COM

IMPORTANT: THIS IS NOT A BINDER
INCOMPLETE & UNSIGNED APPLICATIONS ARE NOT ACCEPTABLE

NAME OF INSURED ( OWNER )

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D.B.A

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MAILING ADDRESS

STREET ADDRESS

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CITY

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STATE

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ZIP

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Business Type

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PHYSICAL ADDRESS WHERE CANINE ( S ) ARE HOUSED / KENNELED

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PHONE NUMBERS

HOME

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CELL

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WORK

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EMAIL ADDRESS

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REQUESTED LIMITS OF LIABILITY (PER OCC / AGG)

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IF OTHER

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PER OCC

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PER AGG

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DEDUCTIBLE (PER CLAIM (BI/PD) INCLUDES L.A.E)

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SCHEDULE OF COVERED CANINE ( S ) TO BE INCLUDED ON THIS POLICY: (INCLUDE ALL REQUESTED INFORMATION )

TOTAL NUMBER OF CANINE ( S ) TO BE INSURED FOR LIABILITY

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TOTAL NUMBER OF ANIMAL ( S ) / CANINE ( S ) OWNED &/OR ON PREMISES NOT ( TO BE ) INSURED ( IF ANY )

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ATTACH (MAIL / FAX) COPY OF ANY AND ALL (FEDERAL, STATE, LOCAL) PERMITS, LICENSES, ETC (IF ANY ARE REQUIRED)

PROVIDE COMPLETE DETAILS OF YOUR FACILITY FOR HOUSING / KENNELING STATED CANINE (S). (IE TYPE OF TRANSPORT CAGE (S) USED)

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PLEASE DOWNLOAD, PRINT, AND SIGN THE "ANIMAL / CANINE WARRANT"

ATTACH ( FAX / MAIL ) CURRENT VACCINE / SHOT RECORDS

DESCRIBE EXACT (COMMERCIAL) USAGE OF ALL SCHEDULED CANINE (S) TO BE INSURED

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ATTACH ( FAX / MAIL ) ANY AND ALL COPIES OF ANY RENTAL / LEASE AGREEMENT (S) &/OR ANY OTHER CONTRACT (S) USED IN YOUR COMMERCIAL OPERATION.

NAME OF PRESENT &/OR PREVIOUS INSURANCE CARRIER

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ANY LOSSES OR CLAIMS IN THE LAST FIVE YEARS FROM THE SCHEDULED OWNED CANINE (S) AS STATED ABOVE OR ATTACHED HERETO?

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IF YES, PROVIDE FULL DETAILS

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PREMISES LIABILITY COVERAGE IS NOT AUTOMATICALLY AFFORDED, THIS MUST BE SPECIFICALLY REQUESTED & ENDORSED (SUBJECT TO ADDITIONAL PREMIUM)

MAIL / FAX A CURRENT COPY OF YOUR VETERINARIAN RECORD (S) FOR ALL SCHEDULED CANINE (S) TO BE INSURED (WTHIN 6 MO)

(WARRANTED ALL OWNED SCHEDULED CANINE (S) IS / ARE CURRENT ON ALL OF THEIR SHOT (S) / VACCINATION (S) AND IN HEALTH AT THE TIME OF THIS APPLICATION IS COMPLETED BY THE NAMED INSURED)

FORWARD A COPY OF ANY AND ALL (RENTAL / LEASE) CONTRACT (S) USED WITH YOUR COMMERCIAL GUARD DOG OPERATION (S)

(WARRANTED THE NAMED INSURED HAS A WRITTEN CONTRACT FOR ALL LOCATION (S) WHERE CANINE (S) IS/ARE CONTRACTED TO GUARD)

WHERE IS / ARE THE DOG (S) / CANINE (S) KEPT WHEN NOT USED

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HOW ARE THE DOG (S) TRANSPORTED TO EACH LOCATION / FACILITY

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HOW MANY EMPLOYEE (S) DO YOU HAVE THAT WORK WITH THE CANINE (S)

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ARE THEY PROPERLY TRAINED WITH THE SPECIES?

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BY WHOM

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IS / ARE THE CANINE (S) PICKED-UP AND DELIVERED DAILY?

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PLEASE EXPLAIN CURRENT ARRANGEMENT

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DO YOU HAVE ANY WRITTEN PROTOCOL (S) ON YOUR COMMERCIAL ANIMAL / CANINE OPERATIONS?

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IF YES, PLEASE ATTACH ( MAIL / FAX ) COPY OF YOUR WRITTEN PROTOCOLS

WILL YOU REQUIRE ANY ADDITIONAL INSURED (S)?

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IF YES - FULL DETAIL (S) (IE NAME, ADDRESS, PHONE, FAX, ETC) FOR EACH REQUESTED - SUBJECT TO ADDITIONAL PREMIUM

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WHAT IS THE ESTIMATED NUMBER OF LOCATION (S) WHERE DOG (S) WILL BE USED AT ONE TIME

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DO YOU CONTRACT / UTILIZE ANY NON-OWNED ANIMAL (S) / CANINE (S) AND/OR ANY INDEPENDENT CONTRACTOR (S) IN YOUR OPERATIONS?

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IF YES, PLEASE EXPLAIN IN DETAIL

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TERM OF POLICY

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IF OTHER

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PROPOSED EFFECTIVE DATE

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REMARKS ( IF ANY )

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IT IS WARRANTED BY THE NAMED INSURED, AND AS A CONDITION PRECEDENT TO LIABILITY COVERAGE ( S ) AFFORDED THAT ALL CANINE ( S ) / DOG( S ) OWNED BY, LEASED, AND/OR RENTED TO AND/OR IN THE CARE, CUSTODY, AND/OR CONTROL / SUPERVISION OF THE RESIDENT HOUSEHOLD MEMBER ( S ) AND/OR GUEST ( S ) ONLY, SHALL BE ATTACHED TO A LEASH, WITH A MUZZLE AND/OR CONFINED ( IN A MINIMUM OF SIX ( 6 ) FOOT HIGH FENCED IN AREA PROPERLY SECURED TO THE GROUND AND/OR IN THE ASSURED'S PERMANENT ( DESIGNATED ) RESIDENCE / HOUSE AND/OR RESTRAINED IN SUCH A MANNER THAT THE CANINE ( S ) / DOG ( S ) CANNOT BE OF HARM TO ANY MEMBER OF THE GENERAL PUBLIC AND/OR INVITEES AND/OR GUEST ( S ) AND/OR OTHER FAMILY MEMBER (S).

NOTE: LIABILITY COVERAGE IS AFFORDED FOR OWNED / SCHEDULED CANINE ( S ) / DOG ( S ) ONLY

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

NOTE: POLICY IS 100% FULLY EARNED AT INCEPTION, UNLESS OTHERWISE STATED

I UNDERSTAND AND AGREE THAT ANY MISSTATEMENT OF WARRANTY OF FACT ON THIS APPLICATION SHALL BE CONSIDERED A VIOLATION OF COVERAGE AFFORDED UNDER ANY POLICY ISSUED ON THE BASIS OF THIS APPLICATION. ( THIS APPLICATION WILL BECOME PART OF ANY POLICY ISSUED AS A RESULT IF ITS SUBMISSION. )

PLEASE INITIAL AND DATE TO ACCEPT TERMS OF APPLICATION

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DATE

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AFTER SUBMITTING YOUR ONLINE APPLICATION:

PLEASE DOWNLOAD, PRINT, AND SIGN THE "CANINE WARRANT ENDORSEMENT"

THIS FORM REQUIRES WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION

***CONFIDENTIALITY NOTICE: This message and any attachments are for the sole use of the intended recipient(s) and may contain confidential and privileged information that is exempt from any public disclosure. Any unauthorized use, review, disclosure, or distribution is prohibited. If you have received this message in error, please contact the sender by phone or electronic mail, and destroy all copies of this message.***

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Commercial Canine Animal Owner's Liability Application Claims - Made

AGENCY: LESTER KALMANSON AGENCY, INC &/OR MITCHEL KALMANSON

NOTE: LIABILITY COVERAGE IS AFFORDED FOR OWNED / SCHEDULED CANINE ( S ) / DOG ( S ) ONLY

NOTE: POLICY IS 100% FULLY EARNED AT INCEPTION, UNLESS OTHERWISE STATED

AFTER SUBMITTING YOUR ONLINE APPLICATION:

PLEASE DOWNLOAD, PRINT, AND SIGN THE "CANINE WARRANT ENDORSEMENT"

THIS FORM REQUIRES WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION