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Animal Rescue Insurance Application
BUSINESS NAME
Business Name
Name
Title
MAILING ADDRESS
Address
City
State
Zip Code
LOCATION ADDRESS
Address
City
State
Zip Code
County
BUSINESS CONTACT INFORMATION
Business Phone
Home Phone
Fax Number
Website Address
Email
BUSINESS INFORMATION
Type of Ownership: Corporation   Non Profit   Other - Please indicate:
How many years have you been in business?
Federal ID Number:
Present Insurance Carrier:    Exp. Date of Insurance:
Have you had any claims in the past 5 years?
Annual Revenues:    501 © 3 Status:
LOCATION INFORMATION - WHERE ADMINISTRATIVE WORK IS DONE
Age of Building:   Sq. Feet of Office Space:
Distance to Fire Hydrant:   Distance to Fire Dept.:
Construction of Building: Frame   Brick
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?
Do you do obedience training?
Are animals trained, owned by you?
Do you offer training to the public?
If Yes, do you have a Liability Waiver signed?
Do you offer a Spay/Neuter Program to the public?
Do you have certified therapy dogs?   If Yes, how many?
Do you have adoption forms with Hold Harmless Waiver?
Do you have any people you pay Perdiem?   1099's  
Do you have any people you sub-contract?
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 operate in more than one state?   If so, how many?
How many events do you participate in?
Provide a list of events:
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?
Where do you get your animals from who are taken into your rescue?
Rescues   Shelters   Private Pet Owners   Puppy Mills   Dog Clubs   Trainers   Kennels  
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?
Do you place a dog/cat into foster care before you evaluate for temperament or aggression?
Do you place your rescue dogs/cats into a foster home who have children?
If so, what is the age of children?
How much past experience in the animal care field do you require your foster home to have?
When a foster goes on vacation, what happens to the foster dog or cat?
Do you allow your foster home to keep an animal that is unadoptable to the public?
Application can only be completed and signed by President, Chairman or Executive Director.

When your application is sent we will need 3 Year Loss History from your present insurance carrier or if no prior insurance then resumes must be emailed to us. Resumes must show background experience in the animal care field and what they do for a living.

All applications must be fully completed and will need to be resubmitted if not completed. This will delay in in you getting a quote in a timely manner.

Before coverage is bound we will need copies of Adoption Contract, Hold Harmless Forms, your Foster Care Application and any Procedure Manuals in place.

I hereby declare that I agree to above.
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
City
State
Zip 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?
I hereby declare that all information above is correct.
   



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2533 South Queen Street | Olde Tollgate Village | P.O. Box 931 | York, PA 17405
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