Animal Liability Application

Fill this out online instead of printing a PDF — it goes straight to Kevin for quoting. Fields marked * are required.

General Information

Proposed effective date

Applicant's name *

Is applicant the animal owner? *

Applicant's mailing address *

Physical location where animals are housed (if different than above)

Insurance History

Current insurance carrier (or last, if none currently) *

Prior carriers — last 3 years

Has the applicant ever had a claim? *

Citations or complaints against the animal(s)? *

Have the animals caused injury to a person or another animal? *

Where was the animal obtained?

Have the animals damaged another person's property?

Have the animals been deemed dangerous or vicious?

Have the animals received obedience training?

5-year loss/claims history (REQUIRED) *

If you have a written loss-run document, this form can't accept file uploads — please email it directly to kevin@kevinbrowninsuranceagency.com and we'll attach it to your file.

Any incident, event, or wrongful act before this policy's start date that could give rise to a claim? *

Has anyone attempted to place this risk with a standard (admitted) carrier? *

Desired Insurance

Note: no coverage can be quoted for commercial operations.

Limit of liability *

Self-insured retention (SIR) *

Higher SIRs generally lower the premium. SIRs of $2,500+ need proof you can cover that amount (e.g. last year's tax return).

Pet Information

Is the pet used for a purpose other than personal companionship?

Do the animals qualify as any of the following?

If yes, supporting documentation may be requested.

Have the animals been trained by a professional?

Have the animals been trained to attack on command?

Veterinarian's name and contact info

Do the animals have all required vaccinations?

Do the animals have all recommended vaccinations?

List everyone who walks the animals

Is your private yard fenced or walled in?

Are warning signs posted about the animals?

Nearest public facility (church, school, park) and distance

Do you have a kennel or secured area for the animals?

How are the animals confined when you're away from home?

Do you use a shock collar or similar electronic restraint?

Are there children in the home?

Do you conduct business from your home?

Are animals required to be registered in your area?

Max # of animals allowed by law in your household

Is coverage required by any municipality, contract, or ordinance?

Is off-premises liability coverage required?

Any travel plans involving the animals in the next 12 months?

Have any of the animals shown aggressive behavior or been involved in a public incident?

Animals to be Insured

0 animal(s)

Add one entry per animal at this location.

Animal 1

# of injuries caused by this animal (enter 0 if none)

Animal Owners Only

Does your yard have a dog run?

Is any dog ever chained up?

Representations & Authorization

By checking the box and typing your name below, you confirm that the information in this application is true, complete, and not misleading, and that the insurer may rely on it to quote, bind, and price coverage. You authorize the insurer and its agents to gather any additional information reasonably needed to evaluate this application, and you agree your typed name below may be treated as your signature for this purpose. You also acknowledge that liability limits can be reduced or exhausted by claims during the policy period, and that requesting reinstatement of a limit is your responsibility, not the insurer's.

I have read and agree to the above. *

I confirm I am not a robot. *

Kevin Brown Insurance Agency · NJ License #3003694894 · 732-813-1161

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South Plainfield, NJ · All 21 Counties