Falkins Insurance Group

Contact Us

Name of Dog / Kennel Club:
Number of Members :
Mailing Address:
City:
Postal Code:
Contact:

Are you a registered Non Profit Club?	YesNo
If you are a Registered Non Profit Club Directors & Officers Insurance may be available, would you be interested:	YesNo
Do you have registered members outside of Canada?	YesNo
Do you have members that attend sessions etc. in the US?	YesNo
Is this Club your Business and to you operate for personal Profit?	YesNo
Describe Legal Structure (Society, Corporation, Etc.)
Full description of operations:
What kind of dogs are in your club and how many would attened a session?
Do you train dogs for protection?	YesNo
If "Yes" in what capacity?
Are firearms used?	YesNo
If "Yes" please describe:
Have you had any claims in the past 5 years?	YesNo
If "Yes" please describe:
Do you currently have insurance in place?	YesNo

If yes plese complete the following:
Name of Insurer:
Policy number:
What coverages & limits are in place:
Annual Premium:
Expiry date:
$1,000,000 Liability?	25 Members or Less 25 Members or More
$2,000,000 Liability?	25 Members or Less 25 Members or More

$250,000 Tenants Legal Liability	Yes No

$5,000 Club Equipment	Yes No

$10,000 Club Equipment	Yes No

$15,000 Club Equipment	Yes No

$20,000 Club Equipment	Yes No

	Contact Information

Name :
Position:
Date:
Telephone Number :
Fax Number :
Email Address :
Once this fully completed form has been received in our office we will contact you with your quotation. Should you wish to bind coverage, the policy will be incepted upon receipt of the original signed form and payment in our office. Falkins Contact Information: Ms. Alva Dietrich Falkins Insurance Group Ltd. 907 Baker Street Cranbrook, BC V1C 1A4 Telephone: 250 426 4737 Fax: 250 426 7499 e-mail:adietrich@falkins.com