Therapy Dog Insurance Application
Applicant Full Name
Street Address
City
State/Province
ZIP/Postal Code
Phone Number
Email Address
Dog Information
Dog's Name
Breed
Age
Weight (kg)
Registration/Certification Details
Insurance Details
Type of Coverage
Liability Only
Liability + Medical
Full Coverage
Coverage Amount
Desired Start Date
Additional Information
Any Previous Insurance Claims?
No
Yes
If yes, please provide details
I confirm all information provided is accurate.