ON-PREMISES EXPOSURES

List all animals kept at the primary residence.

Is any of the following outdoor equipment on the premises?

• Trampolines ___ Yes ___ No

If yes, provide the diameter of each trampoline. ___________

• Playground Equipment ___ Yes ___ No

If yes, provide the height of each separate item. _____________

• Tree House ___ Yes ___ No

If yes, provide the height and dimensions. ______________

• Swimming Pool ___ Yes ___ No

If yes, complete the swimming pool supplement.

Do activities that regularly involve non-family members take place at the residence? ___ Yes ___ No

If yes, describe.

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