Obtain a Quote for Canine Liability Insurance

You can obtain a premium quote for Canine Liability Insurance coverage by completing the online application. Once we receive the application, we will contact you with your quote.

DogBite Application

If you are human, leave this field blank.

General Information:

Requested Effective Date:

Applicant’s First Name:

(Must be Owner of Insured Canine(s)

Last Name:

Significant Other/Spouse First Name:

Last Name:

Applicant’s Mailing Address:

City:

Country United States ------------------------------ Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe

State:

Zip:

Daytime Phone Number:

Evening Phone Number:

Email:

Fax:

Residence Premises: Location where the dog/s live if different from the mailing address:

(Please give the address and the reason why)

Where does your dog(s) primarily go for relief to urinate/defecate:

Enclosed fenced area on all sides:

Yes

No

Underground electric dog containment system:

Yes

No

Goes outside without supervision:

Yes

No

(Do not check this box if your yard is completely fenced)

Permanently tied/tethered outside:

Yes

No

In a permanent outside kennel:

Yes

No

Leash walked

Yes

No

Are there children under 16 living in your home full time?

Yes

No

Do you provide daycare or babysitting service:

Yes

No

Do or will you have foster children in your home:

Yes

No

Has anyone living permanently in your home ever been convicted of animal cruelty or domestic abuse?

Yes

No

Do you breed your dogs?

Yes

No

If Yes, what is the maximum number of litters planned in the next 12 months:

Where does your dog sleep?

Inside home

Garage

Outside, loose in the yard

Permanent outside kennel

Do you live in

Urban area?

Suburban area?

Rural?

Number of Dogs in your home over the age of 8 weeks:

How often is the dog taken to the Vet?

Annually

Often as needed

Never

Are all dogs to be insured, legal and in compliance with laws at your Primary Residence?

Yes

No

If no, please give details:

Number of Dogs in the Household:

Complete for each dog to be insured:

Dog Name

Breed

Gender

Male

Female

Spayed or Neutered

Age

Color

Weight

No Training or Basic Training

Yes

No

Intermediate Training

Yes

No

Advanced Training

Yes

No

Service, Seeing Eye, Hearing

Yes

No

Certified Emotional Support Dog

Yes

No

Therapy Dog, dogs that do volunteer visits at hospitals, classrooms or other facilities and the handler is not paid

Yes

No

Hunting, Sporting off leash, Farm, Herding, Gun

Yes

No

Sled Dog Racing, Mashing, Freighting

Yes

No

Professionally Trained Personal Protection or Guard dog, War or Police Service Dog

Yes

No

Add Dog Remove Dog

Have any of the Dogs to be insured:

Caused a visit by Animal Control, Dog Catcher or other Governmental Agency.

Yes

No

Bitten or scratched a person of any age.

Yes

No

(Complete a claims form for every incident regardless of whether it was reported to an insurance company)

Jumped upon or tripped a person causing bodily injury.

Yes

No

Injured or killed another animal?

Yes

No

Been declared dangerous or potentially dangerous? *

Yes

No

* If your dog is declared dangerous or vicious due to their breed please do not mark yes.

Been the subject of a claim, suit, arbitration or legal proceeding?

Yes

No

(Complete an incident report for every incident regardless of whether it was reported to an insurance company)

Supplement for Canine Liability Insurance; complete one for each occurrence:

Name of the Dog:

Date of Occurrence:

Please describe the event in detail:

Was the Occurrence reported to your insurance company?

Yes

No

What date was the Occurrence reported to the insurance company?

Total amount paid by your insurance company: Defense ($)

Total amount paid by your insurance company: Damage ($)

Was the proper governing body contacted regarding this event?

Yes

No

If no why?

What fines, restrictions, specific requirements were mandated as a result of this Occurrence?

What changes have you made to prevent a similar occurrence from happening again?

Add Supplement Remove Supplement

Coverages and Limits

Coverages and Limits:

$25,000

$50,000

$100,000

$300,000

OtherOther

Complete for each Additional Insured:

(Please do not add your spouse as an additional insured)

Name:

Address:

Contact Name:

Contact Phone:

Relationship:

Landlord

Employer

Governmental Entity

OtherOther

Add Insured Remove Insured

THE APPLICATION MUST BE SIGNED AND DATED BY AN OWNER

Applicant Signature:

Dated:

Print Name:

The applicant understands and agrees that she or he is obligated to report any changes in the information provided in this application which occur after the date of the application.

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Notices

The “Applicant” is the party to be named as the “Insured” in any insuring contract if issued. By signing this Application, the Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the Application and all supplemental information and documents provided in conjunction with the Application are warranties that will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or does provide any false, misleading, or incomplete information in conjunction with the Application, any coverage provided will be deemed void from initial issuance.

Applicable in Kentucky
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Applicable in Louisiana
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.

Applicable to New Jersey
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable to New Mexico
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 civil fines and criminal penalties.

Applicable to Ohio
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.

Applicable in Oklahoma
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 information is guilty of a felony.

Applicable in Oregon
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 may be guilty of insurance fraud.

Applicable in Pennsylvania
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.

Applicable in Maine/Tennessee/Virginia
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Applicable in all Other States
Any person who knowingly 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 also punishable by criminal and/or civil penalties in certain jurisdictions.