Operations

Please select which operations you are involved in and then enter the percentage of business done in that category. Total percentage should be 100%.

Canine Operations

Current Insurance Information

Do you currently have insurance?

Disclosure/Authorization/Declarations

WARNING NOTICE: 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.

The undersigned Applicant authorizes the Company, its agents, and representatives to secure claims information from my current and previous insurance carriers.

Acknowledgement, consent and waiver: Upon purchase coverage will be placed with Conifer Insurance company which is rated by A.M. Best Company as B++. The agent, employees, independent contractors, directors and officers make no representation as to the financial status of the insurance carrier. The undersigned requests and grants authority to place coverage as described above.

The undersigned declares that to the best of their knowledge and belief the statements set forth herein are true. The signing of this application does not bind the undersigned to purchase insurance, nor does review of the application bind the insurer to issue a policy. It is agreed, however, that this application shall be the basis of the contract should a policy be issued.

It is imperative you read your policy closely. Without prior written approval from us, coverage is excluded for government owned housing authorities, bars, repossession work, and executive protection for professional athletes and delegates.