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Since 1947
Governor Insurance Agency, Inc.
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This is only a request for quotation!

No insurance will be bound by completion of this application.

Personal Information
First name:  
Last name:  
E-Mail address:  
Home phone:  
How did you locate our agency?:
How many years experience?:  
 

Business Information
 
Business name:
Street address:  
City:  
County:
State:  
Zip:  
Phone:  
Fax:  
What services do you perform in your business?:
 
 
Ownership type:  
If partnership, partner name:
Are you a N.D.G.A.A. or ABKA Member?
Current Insurance carrier Name:
Date current policy expires:  
Estimated annual receipts:  
Estimated annual payroll:
 

Building Description

(Mobile Groomers, please use home/office as base of operations)

 
Type of construction:  
Does your building have sprinklers?:
 
Is your business located in your home?:
 
If you answered yes to the previous question,
is your business in a separate building on your property?:
 
If you answered yes to the previous question,
what is the building's replacement cost?:
Are you the owner or tenant?:
 
Cost to replace building (if owner):
(Does not apply if your business is operated from home)		  
Cost to replace your contents:
(Include value of pets for sale - if applicable)		  
Total square footage of your building (owner):   shop:    
Year building built:  
If building is more than 25 years old, please list years of updates:
Heating   Cooling  
Plumbing   Roofing  
Electrical
Plate Glass Insurance:
If you answered yes to the previous question, total width of all exterior glass:
Number of groomers:
Independent:
Employee:
 

Kennels/Daycare   (COMPLETE THIS SECTION ONLY IF IT APPLIES)

 
Is your kennel cage free:
Number of kennel runs/Suites:
Construction of runs:
Floors:
Walls:
Maximum number of dogs boarded per day:
Average number of dogs boarded per day:
Are kennels enclosed?:
Are kennels heated/cooled?:
Fence coverage needed?:
Fence Attached/Detached to the building:
Fence Replacement Cost: $
Fence Linear Feet:
Do you require shot records/vaccinations?
Are customers allowed in boarding area unsupervised?
 

Mobile Groomers  (COMPLETE THIS SECTION ONLY IF IT APPLIES)
 
If you own a mobile grooming trailer, we must insure the tow vehicle. Please list the tow vehicle in addition to the trailer.
   

Vehicle 1

  
   
Garage or storage location: (If Different than business)  
Address:
City:
State:  
Zip:  
Description:
Year:
Make:
Model:
ID Number (VIN):
Cost new for:
Base Vehicle(Cab/Chassis): $
Customization: $
Contents (unattached-loose items): $
Finance/Lease Company:
Driver's Name:
Driver's License Number:
Birth Date:  
   

Vehicle 2

  
   
Garage or storage location: (If Different than business)  
Address:
City:
State:  
Zip:  
Description:  
Year:
Make:
Model:
ID Number (VIN):
Cost new for:
Base Vehicle(Cab/Chassis): $
Customization: $
Contents (unattached-loose items): $
Finance/Lease Company:
Driver's Name:
Driver's License Number:
Birth Date:  
Please list any additional comments, questions, or vehicles below.
 

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Governor Insurance Agency, Inc. | P O Box 770, 972 Youngstown-Kingsville Rd. SE, Vienna, Ohio 44473 | E-Mail: info@governorins.com

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