LIVESTOCK MORTALITY INSURANCE COVERAGE APPLICATION
THIS IS NOT A BINDER. NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED AND SIGNED BY THE INSURED.
Desired Effective Date:
*
-
Month
-
Day
Year
Date
Primary Contact:
*
Applicant's Name (as it should appear on the policy):
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
example@example.com
Telephone:
*
Format: (000) 000-0000.
COVERAGE REQUESTED:
*
Mortality
Frozen Semen & Embryos- Transit
Frozen Semen & Embryo - Storage
Aggregate Deductible
Per Occurrence Deductible
Waiver of Sole Ownership
Territorial Extension to include (list countries below):
*
Rows
Name and Registration #, Tattoo #, or Identification
Birth Month/ Year
Sex
Species
Use
Purchase Date
Purchase Price
Insured Amount*
Interest (%)
1
2
3
4
** Amounts other than purchase price are subject to acceptance; please provide justification of value**
Is the applicant the sole owner of the animal?
*
Yes
No
If not, list owners and addresses or lien holders/banks including address below:
Is the applicant domiciled in the United States of America?
*
Yes
No
Has any company cancelled or refused to offer coverage to the applicant?
*
Yes
No
If yes, please explain:
Name and address of Loss Payee if applicable
Is this risk currently insured?
*
Yes
No
If yes, please explain:
Please explain if applicant owns, operates, or has financial interest in any other livestock operations:
*
Are all animals on vaccinations and worming programs approved by a veterinarian:
*
Yes
No
What is the frequency of the vaccination and worming program?
*
Is there any contagious disease on premises, or has there been during the past 12 months?
*
Yes
No
If yes, please provide details
Has any animal(s) owned by you died within the past 24 months?
*
Yes
No
If yes, state number of deaths and causes of death
Are there any other facts within your knowledge not already disclosed affecting or likely to affect the company's acceptance of the request for insurance?
*
Yes
No
If yes, please provide details:
Back
Next
Save
STATEMENT OF HEALTH: PLEASE COMPLETE ONE PAGE FOR EACH ANIMAL ON SCHEDULE
At the inception of the policy, all animals must be sound, healthy, and have no known injury, illness, lameness, disease, or
disability. Any pre-existing conditions are not covered, unless otherwise noted and accepted by the company.
1. Does the animal(s) have any history of injury, illness, lameness, disease, or disability?
*
Yes
No
If yes, please provide details including date and animal's name:
2. Does the animal(s) have any past confirmation problems or defects, illness or disease, injury or disability that could affect its ability to be used as intended?
*
Yes
No
If yes, please provide details:
3. Has the animal(s) received any type of medication (long or short term) for anything other than preventative treatment in the last 24 months?
*
Yes
No
If yes, please list medications:
4. Has the animal(s) been examined or treated by a veterinarian for anything other than routine care in the past 12 months?
*
Yes
No
If yes, please provide details:
5. Has the animal(s) had any bloat or other gastro-intestinal disorder in the past 3 years?
*
Yes
No
If yes, please provide details:
6. Has the animal(s) undergone any surgery (other than castration)?
*
Yes
No
If yes, please provide details:
7. If the animal is a breeding female, has she ever experienced birthing difficulties?
*
Yes
No
If yes, please provide details:
8. If the animal(s) is a female, is she pregnant?
*
Yes
No
If yes, provide last service date and expected due date:
Are there any other facts within your knowledge not already disclosed affecting or likely to affect the Company's acceptance of the request for insurance?
*
Yes
No
Page 2 of 5
Back
Next
Save
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material hereto, commits a fraudulent act, which is a crime and may subject such persons to criminal and civil penalties.
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 post-mortem examination on the livestock that have died in a loss, at your expense, verifying the cause of death.
SIGNATURE OF APPLICANT:
*
DATE:
*
-
Month
-
Day
Year
Date
FRAUD NOTICE - GENERAL WARNING
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
STATE SPECIFIC PROVISIONS
Arkansas
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damage. Any Insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regarding to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of Columbia
WARNING: It is a crime to provide false or misleading information to an insured for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida
Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefits is a crime punishable by fines or imprisonment, or both.
Page 3 of 5
Back
Next
Save
Kentucky
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Louisiana
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Maine
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Maryland
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
New Mexico
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York
All commercial insurance forms, except as provided for automobile insurance: Any person who knowing and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance cat, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the state value of the claim for each such violation.
Automobile insurance forms:
Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
Fire insurance:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or concealed for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. The proposed insured affirms that the foregoing information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstance shall be grounds to rescind the insurance policy.
Ohio
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application of files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony.
Oregon
Any person who, with INTENT TO DEFRAUD or knowing that he is facilitating a fraud against an insurer, submits an application, or files a claim containing a false or deceptive statement MAY BE guilty of insurance fraud. (In this statement the "intent" and "may be guilty" could make it acceptable even though the "false or deceptive statement" is not identified as material.)
Page 4 of 5
Back
Next
Save
Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Auto: Any person who knowingly and with intent to injury or defraud any insurer files an application or claim containing any false, incomplete, or misleading, information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a file of up to $15,000.
Puerto Rico
Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assists or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollar ($5,000), not to exceed ten thousand dollars ($10,000); or imprisonment for the fixed jail term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are presented, the jail term may be reduced to a minimum of two (2) years.
Rhode Island
Property Insurance, Real or Personal: The insurance application form shall indication the existence of a criminal penalty for failure to disclose a conviction of arson.
Tennessee
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
Virginia
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
West Virginia
Any person knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Page 5 of 5
Preview PDF
Save
Submit
Should be Empty: