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Homeowners Application
APPLICANT'S INFORMATION
Name Insured
Effective Date
Address
City
State
Zip Code
Insured Phone #
Email Address
PROPERTY/LIABILITY CORE COVERAGES
Dwelling Personal Liability Limits: $500,000
Appuranant Structures (10% of Dwelling Limit) Medical Payments: $500
Personal Property (70% of Dwelling Limit) Replacement Cost Dwelling and Contents
Loss of Use (20% of Dwelling Limit) HO-3 Special Form Perils (Dwelling)
PROPERTY INFORMATION
Year Built:
If over 25 years old, please list all updates:
Dwelling Limit: $    Dwelling Deductible: $500   $1,500   $2,500
Dwelling Construction:
Frame   Joisted Masonry   Metal   Masonry N-C/Fire Resistive   Manufactured Home   Trailer
If Manufactured Home, is it on a permanent foundation?
Dwelling Roof Material:
Dwelling Sq Ft Area:   # of Stories:
Deadbolts?    Sprinklered?    Percentage:
Alarms?    Type of Alarms:
Number of Families:
Basement?    If Yes: Full   Partial    Basement Sq Ft:
Attached Garage?    If Yes, Sq Ft:
Fireplaces?    If Yes, Explain:
Mortgagee:
PROPERTY/LIABILITY UNDERWRITING
Are there any alternative heating sources (i.e. wood/coal/gas/pellet stoves)?
If Yes, Explain:

Professional installed:
Swimming Pool?
If Yes: Above Ground In-ground Approved Fence Diving Board Sliding Board
Any farming or other business conducted on the premises other than that of the Kennel operation?
If Yes, Explain:
Number of Acres?
If more than five acres, explain land use:
Any residence employees?
If Yes, Number of Full-Time: Part-Time:
Any other residences owned, occupied or rented?
If Yes, Explain:
Any coverage Declined, cancelled or non-renewed within the past three years?
If Yes, Explain:
Are there any animals or exotic pets kept on the premises?
If Yes, Explain:
Do you own any recreation vehicles (snow mobiles, dune buggies, mini bikes, motorcycles, atvs, watercraft, etc.)?
If Yes, Explain:
Is building undergoing renovations or reconstruction?
If Yes, Explain:

Estimated Completion Date:   Estimated Value:
Is house for sale?
If Yes, Explain:
Is there any known lead paint exposure?
If Yes, Explain:
Are there any physical defects that need to be corrected?
If Yes, Explain:
LOSSES IN THE PAST 3 YEARS
Date Description Paid Reserved
   



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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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