Name:
*
First Name
Last Name
Email:
*
Address:
Town of Residence:
*
Please Select
Nicosia
Larnaca
Limassol
Pafos
Phone Number:
*
-
Area Code
Phone Number
Are you an existing client?
*
Νο
Yes - please give details (e.g. policy number, ID, account)
Description of building/property the pet will be residing (i.e. warning signs, fencing and height, gates, apartment or house):
*
Pet's Name:
*
Purchase Price (if applicable):
Type of Pet:
*
Dog
Cat
Type of Breed:
*
Pedigree
Mix Breed
Pet's Age (years/months):
*
Sex of Pet:
*
Male
Female
Dog - Pedigree Breed Description:
*
Cat - Breed Description
*
Dog - Mix Breed Description:
Does your Pet wear a collar with name, address and telephone?
*
Yes
No
Has your Pet been micro-chipped?
*
Yes
No
Has your Pet been neutered or spayed?
*
Yes
No
Has your Pet been vaccinated or boosted in the last 12 months:
*
Yes
No
Has your Pet had any previous history of showing violent tendencies or behavioural problems?
*
Yes
No
Is your Pet currently ill or suffer from any previous conditions ?(If yes, please give full history records):
*
Has your Pet been examined or treated by a vet for anything other than routine vaccinations or neutering in the last three years?
*
No
Yes (If yes provide details)
How many Pets (and types) reside at the same property?
*
Has your Pet been previously insured? (if yes, provide details)
*
Is your dog used for hunting purposes?
*
Yes
No
Important Notes:
1. Please note that this from is for quotation purposes only. If you wish to proceed with a contractual agreement you will be required to submit a proposal form. 2. Our quotation will be based on the information you have submitted, therefore, any alterations and/or misleading information, will cause a revision to the quotation accordingly. 3. We have collected only personal data you have voluntarily provided to us and which are processed solely for the purpose of risk assessment and preparation of this quotation.Where additional information is sought, you will be informed at the time of the data collection. If we do not conclude with a contract any personal data collected will be destroyed immediately. However, in case that you choose us for your policy, we are obliged by law to retain your personal data for a period of at least 13 (thirteen) years after termination.
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