lkalmanson - Individual Canine Liability

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

NOTE: PREMISES LIABILITY COVERAGE IS NOT AUTOMATICALLY INCLUDED

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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MAILING ADDRESS

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CITY

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STATE

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ZIP

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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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IS THE PREMISES WHERE THE CANINE(S) ARE KEPT, BOARDED, & MAINTAINED

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IF RENTED, LEASED, OR NON-OWNED, PLEASE PROVIDE FULL DETAILS OF THE LEASE &/OR RENTAL AGREEMENT
PROPERTY DAMAGE COVERAGE WILL BE EXCLUDED UNLESS OTHERWISE ENDORSED AND IS SUBJECT TO AN ADDITIONAL PREMIUM

REQUESTED LIMITS OF LIABILITY (PER OCCURENCE / PER ANNUAL AGGREGATE)

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IF OTHER

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PER OCC

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PER AGG

DEDUCTIBLE

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IF OTHER

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IS OFF PREMISES COVERAGE REQUESTED?

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IF YES: ALL ANIMALS MUST BE PROPERLY SECURED &/OR ON A LEASH WITH THE NAMED INSURED AND NOT ROAMING AT LARGE

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

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NAME AGE SEX USE BREED WEIGHT WEIGHT TAG#MICRO-CHIP #

CANINE 1

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CANINE 2

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CANINE 3

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CANINE 4

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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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DO YOU HAVE A KENNEL OR SECURED AREA FOR THE ANIMAL?

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IF YES, WHEN AND HOW IS THE KENNEL OR SECURED AREA USED?

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DO YOU HAVE A FENCE ON YOUR PROPERTY?

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IF YES: A) WHAT TYPE OF FENCE

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HOW TALL

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WHAT TYPE OF CONSTRUCTION

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HOW ARE GATES &/OR ENTRANCES SECURED &/OR LOCKED

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ATTACH ( FAX / MAIL ) CURRENT VACCINE / SHOT RECORDS

PLEASE ATTACH ( FAX / MAIL ) ADDITIONAL SCHEDULE OF CANINE ( S ) TO BE INSURED ( IF ANY )

DESCRIBE EXACT USAGE OF ALL SCHEDULED CANINE ( S ) TO BE INSURED ( PET / SHOW / BREEDING / OTHER )

CANINE 1

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CANINE 2

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CANINE 3

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CANINE 4

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

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IF YES, PLEASE EXPLAIN

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PROVIDE FULL DETAIL ( S ) OF THE GENERAL LOCATION / NEIGHBORHOOD WHERE THE CANINE ( S ) ARE KEPT ( IE RURAL / CITY / COUNTY LIMITS ):

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PROVIDE FULL DETAIL ( S ) OF THE INSURED' ( S ) LOCATION / PREMISES USED TO KEEP / KENNEL / HOUSE THE SCHEDULED CANINE ( S ):

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WHAT ( IF ANY ) RESTRICTIONS DO YOU USE TO PREVENT THE SCHEDULED CANINE ( S ) FROM HARMING ANY MEMBER OF THE GENERAL PUBLIC &/OR ANY INVITEE ( S ) &/OR ANY OTHER GUESTS? ( IE TYPE OF FENCING / PEN ( S ) / CAGE ( S ) / MUZZLE ( S ) / ETC )

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HAVE ANY OF THE SCHEDULED CANINE ( S ) TO BE INSURED SHOWN ANY AGGRESSIVE BEHAVIOR OR HAVE BEEN INVOLVED IN ANY INCIDENTS WITH THE PUBLIC?

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IF YES, PLEASE EXPLAIN IN FULL DETAIL FOR EACH INCIDENT

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IS COVERAGE REQUIRED BY A MUNICIPALITY &/OR ORDINANCE?

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IF YES, PLEASE ATTACH ( MAIL / FAX ) A COPY OF THE ORDINANCE REQUIREMENT ( S ).

ARE THERE CHILDREN IN THE HOME?

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IF YES, LIST THE NUMBER OF CHILDREN AND CHILDREN'S AGES

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DO YOU CONDUCT BUSINESS FROM YOUR HOME?

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IF YES: A) TYPE OF BUSINESS

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DO CUSTOMERS, BUSINESS PARTNERS, SALES PEOPLE, OR OTHER SIMILAR BUSINESS VISITORS COME TO YOUR HOME?

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IF YES, IS/ARE THE CANINE ( S ) RETAINED OR CONFINED DURING BUSINESS HOURS?

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DESCRIBE

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HOW ARE THE CANINE ( S ) CONFINED WHEN YOU ARE AWAY FROM HOME?

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NOTE

NO PERSONAL CHECKS ACCEPTED ( MONEY ORDER / CASHIER'S CHECK / CREDIT CARD [ MASTERCARD / VISA ONLY ] )

IF PAYING BY CREDIT CARD, A COPY OF CURRENT VALID DRIVERS LICENSE AND CREDIT CARD FRONT AND BACK MUST BE INCLUDED WITH THE CREDIT CARD AUTHORIZATION FORM ( COVERAGE CANNOT AND WILL NOT BE ISSUED WITHOUT THIS ) - PLEASE MAIL / FAX ALONG WITH CREDIT CARD AUTHORIZATION FORM

POLICY IS FULLY EARNED AT INCEPTION, UNLESS OTHERWISE STATED

INDIVIDUAL CANINE ANIMAL OWNER'S LIABILITY COVERAGE AFFORDED IS LIMITED TO DIRECT (THIRD PARTY) BODILY INJURY &/OR PROPERTY DAMAGE CAUSED BY THE OWNED / SCHEDULED CANINE ONLY

IS/ARE THE CANINE ( S ) / DOG ( S ) MICRO-CHIPPED? IF YES, MICRO-CHIP #S MUST BE LISTED IN DESCRIPTION OF CANINE ( #8 )

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IS THE DOG REGISTERED WITH LOCAL AUTHORITIES?

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IF YES, PLEASE PROVIDE NAME

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ARE THERE "BEWARE OF DOG" SIGNS POSTED ON YOUR PROPERTY?

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IF YES, PLEASE MAIL / FAX PHOTOS OF ALL POSTED SIGNS

NO LIABILITY COVERAGE AFFORDED FOR ANY COMMERCIAL OPERATION AND/OR ACTIVITIES UNLESS SPECIFICALLY ENDORSED HERETO AND AN ADDITIONAL PREMIUM CHARGE IS MADE AND PAID BY THE ASSURED

TERM OF POLICY

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PROPOSED EFFECTIVE DATE

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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

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

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DATE

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CANINE / DOG INSPECTION FORM

THIS FORM IS REQUIRED IF THERE ARE ANY PRIOR BITES AND/OR INCIDENTS

I

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FULLY UNDERSTAND THAT IN ACCEPTING THIS INDIVIDUAL CANINE / DOG LIABILITY INSURANCE POLICY THAT I AM AWARE THAT THERE WILL BE AN INSPECTION OF OUR PROPERTY WHERE OUR OWNED CANINE / DOG IS KEPT

PLEASE INITIAL ACCEPTANCE OF TERMS

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DATE

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PHONE NUMBER

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ALTERNATE PHONE NUMBER

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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

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Individual Canine Animal Owner's Liability Application Claims - Made

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

IF PAYING BY CREDIT CARD, A COPY OF CURRENT VALID DRIVERS LICENSE AND CREDIT CARD FRONT AND BACK MUST BE INCLUDED WITH THE CREDIT CARD AUTHORIZATION FORM ( COVERAGE CANNOT AND WILL NOT BE ISSUED WITHOUT THIS ) - PLEASE MAIL / FAX ALONG WITH CREDIT CARD AUTHORIZATION FORM

***THIS FORM IS REQUIRED IF THERE ARE ANY PRIOR BITES AND/OR INCIDENTS***

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

THIS FORM IS REQUIRED IF THERE ARE ANY PRIOR BITES AND/OR INCIDENTS