PETTING ZOO LIABILITY APPLICATION

CLAIMS MADE LIABILITY POLICY

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

        P.O.BOX 940008

        MAITLAND, FLORIDA  32794-0008  U.S.A.

        PH: 407-645-5000    FAX: 407-645-2810

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                          I M P O R T A N T

           "   T H I S   I S   N O T   A   B I N D E R   "

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     [ INCOMPLETE AND UNSIGNED APPLICATIONS ARE NOT ACCEPTABLE ]

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1) PROPOSED EFFECTIVE DATE:  TERM:

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2) NAMED INSURED:

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3) DBA:

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4) MAILING ADDRESS:

     CITY:   STATE:     ZIP:  

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5) PHYSICAL LOCATION(S)(IE DESIGNATED PREMISES):

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6) ARE YOU CONSIDERED A TRAVELING PETTING ZOO (OPERATION)?

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7) INDICATE NUMBER OF ACRES: (OF DESIGNATED PREMISES)

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8) PHONE:     FAX:

     CELL:     EMAIL:

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9) YEARS IN BUSINESS:

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10)

    IF OTHER:

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11) DESCRIPTION OF YOUR OPERATION(S) / PETTING ZOO (IE. TRAVELING) :

   

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12) REQUESTED LIMITS OF LIABILITY (PER OCC. / AGG.):

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13) DEDUCTIBLE (PER CLAIM (BI/PD)INCLUDING L.A.E.):

    IF OTHER:

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14) ATTACH (MAIL/FAX) COPY OF ANY & ALL ( FEDERAL, STATE, LOCAL ) PERMITS, LICENSES. (IE. OCCUPATIONAL LICENSE ETC.)

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15) ATTACH (MAIL/FAX) A (SPECIMEN) COPY OF YOUR VETERINARIAN RECORDS USED(KEPT).

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16) IS THE PUBLIC RESTRICTED FROM ACCESS TO ALL WORK / STORAGE AREAS?

    IF NO, EXPLAIN:

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17) DESCRIBE SAFETY MEASURES TO AVOID ATTRACTING NUISANCE HAZARD(S):[FENCING, SIGNS (MAIL/FAX A DIAGRAM) ETC.]

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18) DESCRIBE FREQUENCY OF PEN CLEANING/ ENCLOSURE?

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19)  ATTACH (MAIL/FAX) COPIES OF ANY ADVERTISEMENT MATERIALS OR BROCHURES USED

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20)  ANY PRIOR CLAIMS IN THE LAST FIVE (5) YEARS?

    IF YES, PROVIDE DETAILS:

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21) NAME OF PRESENT OR PREVIOUS INSURANCE CARRIER: (INCLUDE LIMITS, DED'T, PREM., ETC.)

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22) WHAT IS YOUR (APPROX.) GROSS RECEIPTS ? $

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23) DO YOU PROVIDE ANY ANIMAL RIDES ? (IE. PONY, ELEPHANT, CAMEL, ETC.)

    IF YES, PROVIDE DETAILS:

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24) DO YOU SERVE / SELL ANY ANIMAL FOOD ?

    IF YES, EXPLAIN:

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25) DO YOU HAVE ANY PROPERTY AND / OR ANIMALS TO BE INSURED ?

    PLEASE PROVIDE SCHEDULE:

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26) ARE ALL PARKING & WALK AREAS MAINTAINED AND KEPT FREE OF DEBRIS?

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27) WHAT IS YOUR EXPERIENCE WITH PETTING ZOOS?

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28) DESCRIBE ALL ANIMAL SHOWS AND EVENTS PERFORMED FOR THE PUBLIC:

    (INCLUDE SCHEDULE OF SHOWS AND EVENTS, ETC., IF ANY)

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29) ARE ALL BARRIERS BETWEEN THE PUBLIC AND THE ANIMALS ADEQUATE

    TO PREVENT CONTACT AND/OR INJURY ?

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30) ARE ALL BARRIERS MAINTAINED FREQUENTLY?

      HOW OFTEN ARE THEY MAINTAINED?

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31) DO YOU HAVE AND / OR GIVE ANY PONY RIDES ?

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32) ATTACH LIST / SCHEDULE OF ANIMALS USED IN YOUR OPERATIONS:

ID/NAME OF ANIMAL - AGE - SEX - SPECIES - MICROCHIP #/PERM. ID - USE - OTHER

A)  

B)

C)

D)

ATTACH SEPARATE LIST / SCHEDULE OF ADDITIONAL ANIMALS IF NEEDED

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33) DO YOU HAVE AND / OR OWN ANY (EXOTIC) DANGEROUS ANIMALS WHICH WILL BE USED IN YOUR COMMERCIAL PETTING ZOO?  

 

IF YES, EXPLAIN HOW USED &/OR PRESENTED:

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34) REMARKS (IF ANY):

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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.

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    ***** NOTE: POLICY IS 35% MINIMUM EARNED AT INCEPTION. *****

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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 OF ITS SUBMISSION.)

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IN CONSIDERATION OF THE PREMIUM CHARGED AT INCEPTION, IT IS HEREBY AGREED AND UNDERSTOOD THAT THE FOLLOWING WORDING IS HEREBY MADE PART OF THIS POLICY:

IT IS WARRANTED BY THE NAMED INSURED, AND AS A CONDITION PRECEDENT TO LIABILITY COVERAGE ( S ) AFFORDED HEREIN OR HEREUNDER THAT ALL ANIMAL ( S ) / SPECIE( S ) OWNED BY, LEASED, AND/OR RENTED TO AND/OR IN THE CARE, CUSTODY, AND/OR CONTROL / SUPERVISION OF THE NAMED INSURED ( S ) SHALL BE ATTACHED TO A LEASH, WITH AN EXPERIENCED ANIMAL TRAINER / HANDLER (UNDER THE DIRECT SUPERVISION OF THE NAMED INSURED(S) AND/OR ITS EXPERIENCED EMPLOYEE(S) AND/OR CONFINED AND/OR RESTRAINED IN SUCH A MANNER THAT THE ANIMAL ( S ) / SPECIE(S) CANNOT BE OF HARM TO THE GENERAL PUBLIC AND/OR INVITEE(S) AND/OR ANY VOLUNTEER(S).

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THIS LIABILITY INSURANCE DOES NOT APPLY TO ANY "BODILY INJURY," &/OR "PERSONAL INJURY," &/OR ANY MEDICAL PAYMENTS (IF AFFORDED) &/OR ANY LEGAL DEFENSES ARISING OUT OF ANY CLAIM(S), ACCUSATION(S), &/OR CHARGE(S) BROUGHT BY AND/OR AGAINST ANY INJURED(S) FOR ACTUAL AND/OR ALLEGED DAMAGE(S) AND/OR INJURIES ARSING OUT OF ANY COMMUNICABLE DISEASE(S) &/OR INFECTION(S), INCLUDING E-COLI INFECTION &/OR BACTERIA, NO MATTER HOW TRANSMITTED, BY ANY (NAMED) INSURED'S &/OR IT'S EMPLOYEES &/OR ANY OF THEIR ANIMAL/SPECIES, INCLUDING BUT NOT LIMITED TO ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) AND/OR ANY OTHER COMMUNICABLE DISEASE(S) AND/OR INFECTION(S) AND/OR BACTERIA.

IT IS FURTHER AGREED AND UNDERSTOOD THAT THIS SPECIFIC COMMUNICABLE / INFECTIOUS DISEASE EXCLUSION ENDORSEMENT WOULD APPLY TO ANY AND ALL CLAIMANT(S) WHETHER INDIVIDUALLY AND/OR AS A CLASS MEMBER OF ANY CLASS ACTION LITIGATION.

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PLEASE INITIAL AND DATE TO ACCEPT TERMS OF APPLICATION (REQUIRED TO PROCESS APPLICATION):

INITIAL     DATE


AFTER SUBMITTING YOUR ONLINE APPLICATION:

PLEASE DOWNLOAD, PRINT, AND SIGN THE "PETTING ZOO LIABILITY" AND "TERRORISM" SIGNATURE FORMS

THESE FORMS REQUIRE WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION


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