Pet Services Insurance Questionnaire

Pet Services Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Pet Grooming | Pet Training | Dog Walkers | Pet Sitters | Kennels | Doggie Day Camps | Pet Waste Cleanup
GENERAL INFORMATION
1. How long have you been in business?
2. In what state(s) do you conduct business?
3. Please describe your experience and operations.

4. Please provide annual receipts below:

	Annual Receipts ($)
Kennels
Pet Grooming
Pet Training
Dog Walkers
Pet Sitters
Doggie Day Camps
Pooper Scooper Waste Removal
Waste Receptacle Installation
Pet Food Products
Pet Care Products
Other
Total Gross Receipts

	Full-Time	Part-Time
Number of Employees

	Vehicle
Year
Vehicle Make
Vehicle Model
Owner/Operated - Yes/No
Lessor Operated - Yes/No
Purchase Date
Purchase Price
Did price include customized grooming area - Yes/No/NA
If no, date vehicle was customized
Cost to customize (Describe below)
Anti-theft devices (Describe below)