Livestock Mortality Application

Livestock Mortality Insurance Application
THIS IS NOT A BINDER. NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED AND SIGNED BY INSURED.
Jaycie Kimpling - Agent

jkimpling@apalis.com

support@agsurance.com

Cell: 309-287-7010

Office: 309-664-5655

216 E. Grove St. Suite 23000

Bloomington, IL 61701
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Policy Period: Month/ Year* to Month / Year* (Coverage begins on date of acceptance.)

Livestock Mortality Rating Plan
Minimum Annual Premium - $250

Rates listed are per $100 of insured value. Age is calculated based on January 1 of birth year for animals one year or older.

Vet Certs required on all exoctics.

Beef Cattle or Bison- $150,000 maximum value Rate

24 hours of age to 14 days of age - Vet Cert Require Refer

15 days to 49 days of age - Vet Cert Required $12.00

50 days to 90 days of age - Vet Cert Required $9.50

Females (cows and heifers) 91 days to 4 years $7.00

Males (Bulls) 91 days to 4 years $7.70

Show Steers- $10,000 maximum purchase price $15.00

Swine - $10,000 maximum value

Age between 60 days to 6 months at inception; or use = show $16.50

Age between 6 months to 4 years of age; and use= breed $13.25

Show barrows - $10,000 maximum purchase price. $16.50

Sheep and Goats - $50,000 maximum value

Age between 60 days to 6 months at inception; or use = show $16.50

Age between 6 months to 4 years of age; and use = breed $13.25

Show Wethers - $10,000 maximum purchase price $16.50

Other Species: $50,000 maximum value

Elk - 6 months to 8 years of age - vet cert required $8.00

Dogs - 6 months to 8 years of age - male/female with whelping exclusion $7.00

Dogs - 6 months to 8 years - Females $9.00

Exotics - Vet Cert Required Refer

Endorsements:

Accidents, sickness, & Disease Infertility

Bulls up to 4 yrs - stud collection only/ no live cover breeding Vet Cert and BSE $2.00

Alpacas - up to 12 years of age, Vet Cert Required $1.00

Rams/Billy GOats up to 4 years of age - Vet Cert and BSE required. Rams must be tested B. Ovis negative $2.50

Frozen Semen and Embryo Endorsement

Storage - $500,000 maximum inventory limit

Transit within the US

Single Trip Transit Coverage

Up to 250 Miles $0.50

251 to 500 Miles $0.75

501 to 1,000 Miles $1.15

1,001 to 1,500 Miles $1.50

1,501 miles or more $2.00

Sale Name: *
Sale Date:*

MonthDayYear
Date
Veterinarian Name: *
Veterinarian Address:*
Veterinarian Phone Number: *

Please Fill out each Column for each animal purchased. *

	Name / Registration / Tattoo / ID	Birth Month/ Year	Sex	Species	Use	Purchase Price	Insured Amount	Interest %
Animal
Animal
Animal

Primary Location Animal(s) is Kept: *
Was the purchase price cash, trade, or both? Explain: *
Are you the sole owner of this animal?*

YesNo
If you are not the sole owner - please explain.
Has current or other carriers ever refused Animal Mortality coverage to you?*

YesNo
If yes, Please Explain:
Any other mortality coverage on any of the animals listed?*

YesNo
If Yes, Please enter the name of the carrier, expiration date, and coverage options:
Have any animals listed received treatment for illness, lameness, accident, or bloating in the last 12 months?*

YesNo
If Yes, Please explain:
Cause of death of cattle owned in the previous 3 years - covered by insurance or not: *

I declare to the best of my knowledge and belief that the animal(s) listed on the above application to be in normal healthy sound condition. I hereby certify that the above information is truthful and accurate. I understand that any fraudulent, omitted, or misrepresented statement voids any policy of insurance issued on the basis of this application. I further understand that the insurer will rely on the information provided in this application, which will become part of any policy issued.

I understand and agree this is not a binder, but merely an application of insurance. I also understand that it is required under the policy to give immediate notice by telephone of any illness, injury, disease, disability, or death of any insured animal. Not doing so may jeopardize coverage and result in denial of any claim.

I understand that it is required under the policy to do the following in the event of a loss, and that not doing so may jeopardize coverage and result in denial of any claim made:

• Give immediate notice by telephone of any loss to insured livestock.

• Do not remove dead livestock until authorized by us, unless legally required to do so.

• Preserve any physical evidence relating to the cause of loss to insured livestock to assist with our claim investigation.

• Have a licensed veterinarian perform a postmortem examination on 10% of the livestock have died in a loss, at your expense, verifying the cause of death.
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Livestock Mortality Insurance Application

Jaycie Kimpling - Agent

Livestock Mortality Rating Plan