Animal Liability Insurance Form

What is your first name? **

What is your first name? *

What is your last name? **

What is your last name? *

What is your email address? **

What is your email address? *

What is your phone number? **

What is your phone number? *

What is your address? **

What is your address? *

Street Address Address Line 2 City State ZIP Code

When do you want this coverage to start? **

When do you want this coverage to start? *

Animal Information

Is the animal you are seeking coverage for a dog? **

Is the animal you are seeking coverage for a dog? *

Yes
No

What type of animal is it? **

What type of animal is it? *

What is the animal's name?

What is the animal's breed?

Is the animal spayed or neutered?

Yes
No

What is the animal's gender?

Male
Femaile

What is the animal's age?

What is the animal's weight?

How many years have you owned this animal? (Put 1 if less than 1 year.)

What color is the animal?

What is the animal's registration tag number?

Has the animal bitten a human or animal?*

Yes
No

How many times has the animal bitten a human or animal? (Enter a number. Ex. 1)

Please enter the requested information for each incident where the animal bit a human or animal.

Adult, Child, or Animal?	Bite Date	Explanation

Were the bites provoked?

Yes
No

Please explain how the bites were provoked for each occurrence.

Has this animal been deemed dangerous or vicious?

Yes
No

Please explain why the animal has been deemed dangerous or vicious.

Is this pet used for a purpose other than personal?

Yes
No

Please provide an explanation for the other purpose(s) this animal has.

Does the animal qualify for any of the following?

Emotional support/comfort animal: These support animals provide companionship, relieve loneliness, and sometimes help with depression, anxiety, and certain phobias, but do not have special training to perform tasks that assist people with disabilities.
Service animal: A service animal means any dog or animal that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability.
Therapy animal: Therapy animals provide with therapeutic contact, usually in a clinical setting, to improve their physical, social, emotional, and/or cognitive functioning.
Commercial/working animal: Any animal being used for or working in a commercial setting.

Does this animal have all required vaccinations?

Yes
No

Do you have any other pets you are NOT looking to insure?

Yes
No

How many pets do you have that you do not wish to insure?

Do you own or rent your home?

Own
Rent

What type of residence do you occupy?

Do you have a kennel or secured area for the animal?

Yes
No

Are there children in the home?

Yes
No

Please list the number of children and their ages.

Number of Children	Children's Ages (I.e. 2, 5, 7)

Do you conduct business from your home?

Yes
No

Please provide an explanation of the business you conduct from home.

Do clients/vendors, etc. come to your residence?

Yes
No

Please explain.

Are the animal(s) restrained or confined during business hours?

Yes
No

Please describe how the animal(s) are confined or restrained during business hours.

How many people do you have walk the animal(s)? (Enter a number. Ex. 2)

Please list the names of the people who walk the animal(s).

Name

Documents and Comments

Please use this field to upload any relevant insurance documents.

Drop files here or

Max. file size: 128 MB, Max. files: 10.

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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *

I agree *

Animal Liability Insurance Form

Animal Information

Documents and Comments

Spencer M Houldin

RiskRevu^TM Newsletter

Contact

Animal Liability Insurance Form

Animal Information

Documents and Comments

Spencer M Houldin

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter