325 Columbia Turnpike, Florham Park, NJ 07932 1-877-538-6300

Rescue General Liability Application

Rescue General Liability Application

Please complete this form electronically to ensure that we can respond to your request quickly.

Organization Name:
Applicant First name:
Applicant Last name:
Address:
Address 2:
City: State: Zip Code:
Telephone: Email Address:
Requested Effective Date of Policy: mm/dd/yyyy
Number of Employees:
If your state is NY you must complete this section.
Physical Address:
Physical Address 2:
Physical City: Physical State: Physical Zip Code:
To qualify, please answer the below questions:
Yes No Does your organization own, rent or have unrestricted access to a facility that houses animals 24/7 and has public viewing hours?
Yes No Are your animals housed exclusively in foster homes, vet offices, PetCo / PetSmart stores or boarding kennels.
Yes No Is public access to your animals only at prearranged adoption events at off site locations and / or scheduled visits to foster homes.
Yes No Are you aware of any current circumstances that may give rise to a claim being brought against you and/or your organization that may be covered by this policy.
Yes No In the last five years, are you aware of any known legal actions or threats of legal action brought against you in relation to your rescue group activities?
Yes No Do you grant permission to have any of your insurance policies or documents delivered to you by email?
I declare that after proper inquiry the statements and particulars given above are true and that I have not mis-stated or suppressed any material fact.

I agree that this application form, together with any other material information supplied by me shall form the basis of any contract of insurance effected thereon.

I undertake to inform underwriters of any material alteration to these facts occurring before completion of the contract.

Full Name:
Title:
Date: 09/26/2017