Animal Liability Exclusion Acknowledgement - Complex Coverage

1 Complex Coverage , Inc. 7 High Street; Suite 408 Huntington, NY 11743 Date: Name: Address: Animal Liability Exclusion Under SECTION II, Liability COVERAGES, Coverage E Personal Liability & Coverage F Medical Payments there is no Coverage for damages caused by or originating from any dog or other Animal , including those characterized as exotic or vicious or which has a history of biting that is owned by, or in the care, custody or control of any insured person, or that of your employee or agent. This Exclusion can be found on form OHE32H-0608, New York Mandatory Special Provisions , in your policy documents. This policy does not provide Coverage for: bodily injury, property damage or personal medical payments caused by any Animal owned by, or in the care of the insured; or bodily injury, property damage or personal medical payments caused by prohibited breeds of dogs owned or kept by any insured whether or not the damage occurs on your premises or any other location.

2 Prohibited breeds of dogs include any mix of the following breeds: American Staffordshire Terriers, American Pit Bull Terriers or Staffordshire Bull Terriers (commonly known as Pit Bulls), German Shepherds, Akitas, Chows, Rottweilers, Presa Canario, wolves, any dog with any history of biting, any dog trained to attack persons, property or other animals and any dog that has not had inoculations as required by law. These exclusions apply both on and off the insured premises. I, _____, have been advised of the above referenced Exclusion on my policy. I fully understand that my policy offers no Coverage for any claims resulting from dog bites on or off of my property.

3 X Insured Signature Date Please return with signature upon receipt to your underwriter. Failure to do so will result in cancellation of your policy.