Application Forms

BUSINESS NAME
Business Name
Owner's Name
MAILING ADDRESS
Address
City
State	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
LOCATION ADDRESS
Address
City
State	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
County
Township/Territory
BUSINESS CONTACT INFORMATION
Business Phone
Home Phone
Fax Number
Website Address
Email
BUSINESS INFORMATION
How long have you been in business?
How many years experience do you have with this type of business?
Type of Entity: Sole Proprietor   Partnership   Corporation   Other - Please indicate:
Federal ID Number:
Current Insurance Company:    Current Insurance Premium:
Have you had any claims in the past 3 years? Yes No   If so, please provide date of claim and details below:
BUILDING INFORMATION
Do you own the building? Yes No
If you are a tentant, do you need glass coverage? Yes No
If yes, # of Panes: Width:
Building 1: (If you are a tenant only complete the questions with asterisks*)
*Use of Building:
Building Value:    *Business Personal Property Value:
*Construction Type:    *Total Sq. Ft:    *# of Stories:    *Year Built:
Building Improvements: Wiring Year    Roofing Year    Plumbing Year:    Heating Year:
Roof Type:    *Is this building Sprinklered? Yes No    If yes, what percentage? %
*Is there a Fire Alarm? Yes No    *Is there a Fire Alarm? Yes No    Are these alarms: Central Local
Building 2: (If you are a tenant only complete the questions with asterisks*)
*Use of Building:
Building Value:    *Business Personal Property Value:
*Construction Type:    *Total Sq. Ft:    *# of Stories:    *Year Built:
Building Improvements: Wiring Year    Roofing Year    Plumbing Year:    Heating Year:
Roof Type:    *Is this building Sprinklered? Yes No    If yes, what percentage? %
*Is there a Fire Alarm? Yes No    *Is there a Fire Alarm? Yes No    Are these alarms: Central Local
Building 3: (If you are a tenant only complete the questions with asterisks*)
*Use of Building:
Building Value:    *Business Personal Property Value:
*Construction Type:    *Total Sq. Ft:    *# of Stories:    *Year Built:
Building Improvements: Wiring Year    Roofing Year    Plumbing Year:    Heating Year:
Roof Type:    *Is this building Sprinklered? Yes No    If yes, what percentage? %
*Is there a Fire Alarm? Yes No    *Is there a Fire Alarm? Yes No    Are these alarms: Central Local
How many miles to the nearest fire department:    Distance to fire hydrant:
Kennel Surface: Stone   Concrete   Dirt   Other  - If Other, please explain:
OPTIONAL COVERAGES
Business Computer Value:    Which building is computer located?
Value of fencing attached to building:    Value of fencing not attached to building:
Value of Sign:
QUESTIONS
Are you a member of the Amercian Boarding Kennel Association? Yes No
Are you a member of the American Groom Shop Association? Yes No
Number of animals boarded when full?    Average boarded per week?
Approximate annual boarding receipts?
Do you provide a "Boarding Contract" for your customers? Yes No    If yes, please email a copy of this.
Do you provide grooming services? Yes No    If yes, # of animals groomed daily?   Annual Receipts?
Do you breed animals? Yes No    If yes, name of breed(s):
If you breed, how many litters per year?    Maximum value of each litter:
Do you provide any training? Yes No    If yes, type of training:
Do you employ a Veterinarian? Yes No    If yes, Number of Veterinarians:    Annual Receipts:
Do you have an evacuation plan in place to remove animals in case of a fire? Yes No
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis on the contract should a policy be issued. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I hereby declare that I agree to above.
DOG TRAINER SUPPLEMENTAL GENERAL LIABILITY FORM
Please complete this form below only if you indicated you provide Dog Training.
What kind of training are you qualified to do?
How many years have you been a trainer?
What professional organizations do you belong to?
Do you train on your premises? Yes No    Do you train off premises? Yes No
If you train off premises do you have one specific location or several?
If you train off premises, how often?
Are you a professional dog handler? Yes No
How many dogs have you titled in shows and/or trials?
What breeds do you train
Estimated Gross Annual Receipts?
For over 20 years, Kennel Pak, Inc. has provided the boarding kennel industry a unique insurance package that cannot be offered by any other St. Paul/Travelers representative. The Kennel Pak policy combines property and liability covers for both your business and home if they are located on the same property. Kennel Pak, Inc. is a registered trademark and has been trademarked since 1986. We are endorsed by the American Boarding Kennels Association and have kept that endorsement since 1987. No other agent, broker or organization may use "Kennel Pak" or marker our insurance program without the express written consent of Gentzler & Smith Associates, Inc. and/or Kennel Pak, Inc. By signing this part of the application, you are authorizing Kennel Pak, Inc. & Gentzler & Smith Associates, Inc. to obtain a quote via our program with the St. Paul/Travelers Insurance Company. I hereby declare that I agree to above.
FLOOD INSURANCE NOTICE/REJECTION
Flood insurance is available under the National Flood Insurance Program (NFIP) in over 18,000 communities nationwide. It provides coverage for residential and non-residential buildings and their contents, in both high risk as well as low risk areas. Historically, about one quarter of all losses under the NFIP are in low risk areas. The standard homeowners or commercial property insurance policy typically exlcudes or does not otherwise provide coverage for flooding events. Purchasing separate flood insurance coverage will allow covered flood losses to be adjusted in a similar manner as losses from other perils in other property policies. The Federal Emergency Management Agency (FEMA) advises that although federal disaster relief assistance is sometimes available after a flood, such financial assistance is typically in the form of a loan and must be repaid to the Government in addition to any other outstanding loans. VOLUNTARY ELECTION NOT TO PURCHASE FEDERAL FLOOD INSURANCE I understand that flood insurance coverage is available for the property located at the address entered above, but I hereby elect not to purchase such coverage.
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