Animal Shelter Insurance Program (Pennsylvania)
Business Name:
Contact Person:
Mailing Address:
City:   State:  Zipcode: 
Phone Number:     Fax: 
E-Mail:
Federal ID #:     Business Organization: 

Current Insurance Information:
Insurance Company:  Expiration Date:

Number of Years in this business:     Year of experience in same or related business: 

Hours of Operation: 
 
 
COVERAGES VALUE
Building:
$ 
Business Personal  Property/Contents:
$ 
Property Deductible:
$ 
Computer Equipment & Media ($ 40,000 equipment & $ 10,000 media included):
$ 
Employee Dishonesty ($ 25,000 included):  # of Employees: 
Outdoor Signs ($ 5,000 included):
$ 
Tenant's Exterior Glass:
Linear Feet
Valuable Papers & Records ($ 25,000 included):
$ 
Liability Limit:
Building Information:
Contruction:
Year Built:
  # of Stories:
Ground Floor Square Footage:
Building Updates (if premises is over 25 years old, give date and extent of renovation....
TYPE YEAR
DONE		 DESCRIPTION OF RENOVATION
Electrical
Heating
Plumbing
Roof

Quality of Building:  Basement? Yes / No    Central Air Conditioning? Yes / No

Interest of Insured:         Percentage of building you occupy: %

For buildings with apartments:
Aparment Occupancy: Yes / No     (If "yes", percentage of building: %)       # of Apartment Units: 
Second means of egress in apartments? Yes / No        Emergency Lighting: Yes / No

Building Protection:
Central Alarm System: Local Only / Central System (monitored)

Sprinkler System? Yes / No   If "Yes", % sprinklered

Do you operate any of the following?

Gift Shop: $    Pet Training: $ 
Pet Grooming: $ 
GENERAL QUESTIONS
Does your organization provide shelter for large, wild or exotic animals? Yes / No
How many veterinarians are employed?
Do you have a hospital facility where spays and neuters are performed? Yes / No
Is there a Euthanasia room? Yes / No
Does your organization employ Humane Police officers?
If YES.....
Do the officers have citation or arrest authority?  Yes /  No
Do the officers carry firearms?  Yes /  No
Does separate liability coverage apply to animal control officers? Yes /  No		 Yes / No
What is the average number of visitors at your facility per day?
Do you have any off-site adoption locations? Yes / No
Do you operate any mobile adoption vehicles? Yes / No
Do you have procedures in place for screening adoptive families?
If YES, explain 		 Yes / No
How do you screen for dogs with aggressive tendencies? 
Do you permit dogs with aggressive tendencies to be adopted?
If YES, do you fully disclose the aggressive tendencies to the adoptive parents?
Yes / No
Do you have a contract/agreement in place with a municipality that you will pick up
stray animals on an emergency basis?		 Yes / No
Does your organization provide accident insurance for your volunteers?
If yes, provide:
Insurance Company Name:       Policy Number: 
Policy Period:       Limits: 		 Yes / No
McGrath Insurance Group, Inc.
4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474 (FAX) 327-7911
Toll Free: 1-800-977-2999