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Animal Shelter 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: Non Profit Corp.   Sole Prop.   Other - Please indicate:
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.

I hereby declare that I agree to above and that all the information entered is correct.
ADDITIONAL POLICIES AVAILABLE IF NEEDED
COMMERCIAL UMBRELLA:
Liability Limit:
COMMERCIAL AUTO:
Liability Limit:      PIP Limit:    Medical:    Uninsured:    Underinsured:    Comprehensive Ded.:    Collision Ded.:
YEAR, 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
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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Kennel Pak, Inc.® - Kennel Insurance
2533 South Queen Street | Olde Tollgate Village | P.O. Box 931 | York, PA 17405
Ph. 717-741-0965 or 800-237-7015 | Fax: 717-741-4720 | comments@kennelpak.com
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