DOG INSURANCE
OnLine Application

Name:
Address:
City:
State:
Zip:
Home Phone:
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Fax Number:
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I/Wehereby apply for insurance against loss by death resulting from disease or accidental injuries for the term of 1 MONTH 3 MONTHS 6 MONTHS 1 YEAR 2 YEARS 3 YEARS  on the following described animals:

Name of Animal #1:
Reg. and/or Tatto#:		Sex:	MALE FEMALE	Breed:
D.O.B.:		Purchase Price:		Purchase Date:
Was the Purchase Price: Cash: Trade: Cash/Trade: Leased: On Trial: Homebred: Other: Trainers Name:  Traniers Phone Number: Amount of Insurance: Value Is Based On Which of the Following: Appraisal: Private Purchase: Auction Purchase:

Name of Animal #2:
Reg. and/or Tatto#:		Sex:	MALE FEMALE	Breed:
D.O.B.:		Purchase Price:		Purchase Date:
Was the Purchase Price: Cash: Trade: Cash/Trade: Leased: On Trial: Homebred: Other: Trainers Name:  Traniers Phone Number: Amount of Insurance: Value Is Based On Which of the Following: Appraisal: Private Purchase: Auction Purchase:

Name of Animal #3:
Reg. and/or Tatto#:		Sex:	MALE FEMALE	Breed:
D.O.B.:		Purchase Price:		Purchase Date:
Was the Purchase Price: Cash: Trade: Cash/Trade: Leased: On Trial: Homebred: Other: Trainers Name:  Traniers Phone Number: Amount of Insurance: Value Is Based On Which of the Following: Appraisal: Private Purchase: Auction Purchase:

Name of Animal #4:
Reg. and/or Tatto#:		Sex:	MALE FEMALE	Breed:
D.O.B.:		Purchase Price:		Purchase Date:
Was the Purchase Price: Cash: Trade: Cash/Trade: Leased: On Trial: Homebred: Other: Trainers Name:  Traniers Phone Number: Amount of Insurance: Value Is Based On Which of the Following: Appraisal: Private Purchase: Auction Purchase:

In making application for this insurance, I/We declare the above facts confirm my knowledge and also that this insurance has not been refused elsewhere, no other insurance is in effect, or that insurance is in excess of fair market value. I/We declare that I/we are the sole owner of the animal(s) herein described and that same is now in sound and good condition; and that there is not now, nor has there ever been any contagious disease in my/our vicinity; and that I/we know of no reason why this insurance should not be granted. The following notice is required by various states: “Any person who knowingly with the intent to injure, defraud or deceive any insurance company or other persons, files an application containing any false information or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent act, which is a crime.”

STATEMENT OF CONDITION
I declare to the best of my knowledge and belief that the animal or animals listed on the above schedule to be in normal healthy sound condition. I further declare that during the past policy year the above listed animals have been free from any ILLNESS, INJURY, DISEASE OR ACCIDENT.  I understand and agree that this renewal certificate shall be the basis of the insurance contract and if anything be falsely stated or information withheld to influence the company's decision, the insurance contract will be null and void.

DECLARATION
I, the undersigned, hereby apply to insure the above mentioned animals owned by me, subject to the terms and conditions of the policy to be issued, and I declare that to the best of my knowledge and belief the above statements are true and complete and that I have not withheld any material information. Signing this form does not bind the applicant to complete the insurance but it is agreed that  this form shall be the basis of the contract should a policy be issued and if anything be falsely stated or information withheld to influence the company's decision, the insurance contract will be null and void.

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Date:

 

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