Fillable Animal Services Program Supplemental Application (RT Specialty)

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Animal Services Program Supplemental Application (RT Specialty)

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The Animal Services Program Supplemental Application (RT Specialty) form is 5 pages long and contains:

  • 3 signatures
  • 22 check-boxes
  • 134 other fields

Country of origin: US
File type: PDF

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Animal Services Program Supplemental Application
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent:
Phone:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Property Damage Extension limits [GLS(HI)-55s]:
$ 500 Occurrence/$1,000 Aggregate (Included)
$1,000 Occurrence/$2,500 Aggregate
$2,500 Occurrence/$5,000 Aggregate
2. Indicate annual sales, total number of kennels and average daily number of animals for each applicable
exposure:
Kennels: Kennel is defined as “each individual compartment”
used for housing an animal.
Annual Sales
Total No.
of Kennels
Average Daily
No. of Animals
Animal Adoption Service $
Animal Hotel and/or Pet Day Care Center $
Animal Shelter $
Breeding, Boarding or Sales $
Humane Society $
Rescue Shelter $
Other:
$
Gift and/or Thrift Shops $
GLS-APP-70s (10-13) Page 1 of 5
Submit Application
3. Indicate annual sales or N/A (not applicable) for each of the following described operations/services:
Description of Operations/Services Annual Sales Description of Operations/Services Annual Sales
Animal Catchers:
• Advise type of animals:
$ Riding Academies $
Stables (boarding, livery or racing) $
Therapy Dog Services $
Animal Rescue Services $
Training Operations:
Animal Rides Incl. Sleigh/Carriage
Ride
$ • Bedbugs/Termites $
• Drugs, Explosives or Firearms
Detection
$
Animal Shows or Contests $
Behavioral/Psychiatry Consultants $
• Exotic Animal Training for use in
TV, Movie, Commericials, Videos
or Theatrical Shows
$
Excrement and/or Carcass
Removal Services
$
Horseback Riding Instruction $
• Guard Animal Operations
No. of Animals:
$
Horseback Riding Therapy $
Livestock: $
• Guard Animal Training $
• Artificial Insemination Services $
• Guide/Companion Animal Training $
• Auction $
• Horse Training $
• Breeding $
• Hunting Dog Training $
• Dealers $
• Medical Conditions $
• Other:
$
• Mold $
Pet Grooming Incl. Mobile Grooming $
• Obedience Schools $
Pet Sitters $
• Therapy Dog Training $
Pet Store $
Veterinarian Services $
Pet Walkers $
Veterinary Hospitals or Clinics $
Petting Zoo/Zoos/Wildlife Reserves $
Other: $
Pony Sweeps $
4. Does applicant provide foster care services? ........................................................................................ Yes No
a. Annual receipts from foster care:
b. Average daily number of animals in foster homes:
c. Maximum number of foster animals per home at any one time:
d. Average daily number of foster homes participating:
e. Do all foster homes have a fenced yard? ............................................................................................. Yes No
f. Does applicant have foster care guidelines? ........................................................................................ Yes No
If yes, attach with submission.
5. Does applicant provide therapy dog services? ...................................................................................... Yes No
a. Have all dogs used in this service passed the American Kennel Clubs Canine Good Citizen Test or
equivalent and have additional required training to have certification/title as a Therapy Dog? ............
Yes No
b. Name of organization or association that has provided certification:
6. Is applicant licensed by the United States Department of Agriculture (USDA)? ................................ Yes No
If yes, provide license number:
7. Does applicant follow the practices and regulations of the Animal Welfare Act? ............................. Yes No
GLS-APP-70s (10-13) Page 2 of 5
8. Check all organizations in which the applicant is a member of:
American Animal Hospital Association (AAHA)
American Boarding Kennels Association (ABKA)
American Humane Association (AHA)
American Society for the Prevention of Cruelty to Animals (ASPCA)
American Veterinary Medical Association (AVMA)
Humane Society of the United States (HSUS)
Intergrom
National Association of Dog Obedience Instructors
National Association of Professional Pet Sitters
National Dog Groomers Association of America, Inc. (NDGAA)
Pet Industry Joint Advisory Council
Society of Dog Trainers
Other—Describe:
9. Does applicant import animals? .............................................................................................................. Yes No
If yes, is applicant a licensed customs importer subject to regulation by the U.S. Department of
Customs? .....................................................................................................................................................
Yes No
10. Breeding:
Type of animal: Dog Cat Other—Describe:
Breed(s):
Number of litters sold per year:
Total number of animals sold per year:
11. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
12. Does applicant have any other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable to Oregon).
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
GLS-APP-70s (10-13) Page 3 of 5
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 shall also be subject to civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
GLS-APP-70s (10-13) Page 4 of 5
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
GLS-APP-70s (10-13) Page 5 of 5
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Animal Services Program Supplemental Application (RT Specialty)

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Completed 13 December 2020

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