Animal Shelter Insurance Application

Hidden

Status

Business Name

Name(Required)

First Last

Title

Mailing Address

Address

Street Address Address Line 2 City State ZIP Code

Location Address

Address

Street Address Address Line 2 City State ZIP Code

County

Business Contact Information

Business Phone

Home Phone

Fax Number

Website Address

Email(Required)

Enter Email Confirm Email

Business Information

Type of Ownership:

Sole Prop.

Non Profit Corp.

Other

How many years have you been in business?

Federal ID Number

Present Insurance Carrier

Exp. Date of Insurance

Do you have your 501 (3) C Status?

Have you had any claims in the past 3 years?

BUILDING INFORMATION

Building 1:

Use of Building:

Construction Type:

Total Sq. Ft

Year Built:

Replacement Value:

Value of Contents:

If building is over 30 years old, when were updates done?

Wiring Year

Roofing Year

Plumbing Year:

Heating Year:

Building 2:

Use of Building:

Construction Type:

Total Sq. Ft:

Year Built:

Replacement Value:

Value of Contents:

If building is over 30 years old, when were updates done?

Wiring Year

Roofing Year

Plumbing Year:

Heating Year:

Building 3:

Use of Building:

Construction Type:

Total Sq. Ft:

Year Built:

Replacement Value:

Value of Contents:

If building is over 30 years old, when were updates done?

Wiring Year

Roofing Year

Plumbing Year:

Heating Year

Are any buildings vacant?

Value of Computers:

If you are a tenant, are you responsible for glass coverage?

Value of Fencing attached to building:

Unattached:

Is your fencing chain linked?

Is fencing at least 6 ft?

Distance to Fire Hydrant:

# Miles to Fire Dept.:

Total Revenues:

# Animals when full:

Do you do training?

Do you have a Liability Waiver signed?

Do you offer training to the public?

Do you have certified therapy dogs?

If Yes, how many?

Do you have Vets?

If Yes, are the Employees?

Contracted?

Do you have Animal Control Officers?

If Yes, complete the Animal Control Officers Supplemental Application (listed below)

Is there a crematory on premises

Do you have an adoption form with a Hold Harmless Waiver?

Do you use pet stores as a source for adoptions?

If so, please complete the Supplemental Pet Store Application portion of the form below.

Do you have any people you pay Perdiem?

1099's

Do you have any people you sub-contract?

How many events do you participate in?

Provide a list of events:

ANIMAL CONTROL OFFICERS SUPPLEMENTAL APPLICATION

Please complete this form below only if you indicated you have Animal Control Officers.

Are they Employees?

Volunteers?

Do you have a contract with City of Twp for Animal Control?

Do you contract any Animal Control Officers?

If Yes, do they have their own professional liability insurance?

Are any authorized and certified to carry fire arms?

If your Humane Officers are employees, what procedures do they follow?

State Certification or License required?

How many hours are required for state certification?

Are continuing education classes required?

Do you have a procedure manual in place?

Are officers court appointed?

Do your Humane Officers have the juristation to seize animals from the premises?

Is a search warrant required before entering the premises?

What are your procedures in a hostile situation?

Do your Humane Officers carry firearms?

List names of your Humane Officers:

Volunteer Information

Do you have Volunteers?

If Yes, # of Volunteers

What kind of training do you provide for your volunteers?

Length of training period for volunteers

Do you have all volunteers sign a Hold Harmless Waiver?

Is there a Volunteer Procedure Manual in place?

Do you require any background experience in the animal care field for volunteers?

What is the age limitation for volunteers?

Do you require a Parent or Guardian to sign for volunteers under the age of 18?

Do you require a Parent or Guardian to be present with under age volunteer when doing volunteer duties?

FOSTER CARE INFORMATION

# Foster Care Homes:

How are they evaluated?

Is there an application that foster homes must complete?

Do you have them sign a Hold Harmless Waiver?

Is you foster care applicant a volunteer?

What kind of training is provided for foster homes?

EVALUATION PROCEDURES ON RESCUED ANIMALS

How are animals evaluated?

How are animals handled if they show aggression?

Are animals still placed if there is aggression towards People?

Other Animals?

Food?

What procedures are taken if the animal has bitten someone?

Who makes the decision if the animal has to be euthanized?

If you have an animal that is a known biter, do you place it up for adoption?

Before coverage is bound we will need copies of the following: 3 Year Loss History, Pictures of Facility, Copies of your Adoption Contract, Hold Harmless Waivers, Foster Care Agreement and any Procedure Manuals.

ADDITIONAL POLICIES AVAILABLE IF NEEDED

COMMERCIAL UMBRELLA:

Liability Limit:

COMMERCIAL AUTO:

Liability Limit:

PIP Limit:

Medical:

Uninsured:

Underinsured:

Comprehensive Ded.

Collision Ded.:

YEARL, MAKE, MODEL, ID#:
Enter the Year, Make, Model, and ID# for all vehicles below.

Vehicle #1:

Vehicle #2:

Vehicle #3:

Vehicle #4:

Vehicle #5:

Worker Compensation - Federal ID#:

Clerical Class Payroll:

# FT Emp:

# PT Emp:

Kennel/Vet/Dr. Payroll:

# FT Emp:

# PT Emp:

DRIVERS LIST

Vehicle Operators including any Volunteers.

Include: FULL NAME, DATE OF BIRTH, DRIVERS LIC# and STATE

Driver #1:

Driver #2:

Driver #3:

Driver #4:

Driver #5:

Driver #6:

Driver #7:

Driver #8:

Driver #9:

Driver #10:

SUPPLEMENTAL APPLICATION FOR ORGANIZATIONS WHO USE PET STORES FOR OFF SITE ADOPTIONS

Complete the form below if you use Pet Stores as a source for Adoptions.

Store Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Construction of Building:

Masonary

Frame

Age of Building

Distance to Fire Dept:

Distance to Fire Hydrant

Do you house animals at the store on a full-time basis?

If Yes, # of Cats:

# of Dogs

Who maintains the care of the animals?

Do you take animals to the pet store for one day adoptions?

If Yes, # of Cats:

# of Dogs

# of Volunteers or Employees who oversee the adoption day:

How often do you do the one day adoptions?

What supervision is provided at the adoptions?

Do you have written procedures in place for volunteers or employees who oversee the adoption?

What kind of training & education do you provide for your volunteers or employees in regards to "A Safe Adoption Event"?

Are signs posted on cages "Warning to Keep Hands/Fingers Out"?

Are dogs leashed when outside of cages/crates?

Is there a designated area roped off to keep the public from interacting with the animals?