Livestock Mortality Insurance Application

Ryan Thurston | C: 301-302-3603 | Ryan@boundsins.com

This application does not guarantee coverage or eligibility. One of our licensed agents will express notification of coverage.

Desired Effective Date*

Date

Named Insured*

Address*

Address

Street Address Line 2

CityState:

Postal / Zip Code

Email*

example@example.com

Phone*

Livestock Mortality Insurance Term requested*

30 days3 Months6 Months9 Months (not avail for cattle)1 YearASD (MALE Sheep/Goats- Permanent/Full Infertility Endorsement. Requires vet cert for sheep and goats, and B.Ovis Negative blood test for sheep.)

I understand all policies are fully earned. The entire premium for this policy and animal(s) is non-refundable. No refunds or exchanges.*

Animals insured:

	Permanent ID	Birth Month and Year MM/YYYY(4 digits for year!)	Sex(MC if castrated)	Species (Sheep/Pig/Goat/Cattle) (Cattle Indicate Breed)	What Use: Show OR BREED OR Show/Breed	Purchase Date Or Type the word "Lease"	Purchase Price or Type the word "Lease"	Insured Amount (Purchase price or JOV required.)	Ownership %or type the word "Lease"	Insurance Rate if known
1.
2.
3.
4.
5.

Has the applicant ever been denied or cancelled coverage*

YesNo

Is the risk currently insured?*

YesNo

If YES, with whom:

Are all animals on vaccination and worming programs approved by a vet*

YesNo

Loss payee information IF OTHER THAN named insured. For Lease agreements- Owners name AND ADDRESS HERE:

Include name and address.

At the inception of this policy, all animals must be healthy and sound and free from all illnesses, injuries, lameness, and disease. No coverage for pre-existing conditions unless accepted by company.

1. Does the animal(s) have any history of injury, illness, lameness, disease or disability?*

YesNo

If yes, please provide details:

2. Has the animal(s) received any type of medication for anything other than preventative treatment in the past 12 months*

YesNo

If yes, please provide details:

3. Has the animal(s) been examined or treated by a vet for anything other than routine care in the past 12 monts*

YesNo

If yes, please provide details

4. Has the animal(s) had any bloat or other gastro-intestinal disorder in the past 3 years?*

YesNo

If yes, please provide details

5. Has the animal(s) undergone any surgery other than routine castration, artificial insemination, or surgical flush procedure?*

YesNo

If yes, please provide details:

6. If the animal(s) is a breeding female, has she ever experienced birthing difficulties?*

YesNo

If yes, please provide details:

7. If the animal(s) is a female, is she currently pregnant?*

YesNo

If yes, please provide due date

Date

8. Are there any other facts within your knowledge, not previously disclosed that would likely affect the insurer's acceptance of this request for coverage?*

YesNo

If yes, please explain in detail

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*

Date

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.

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.

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

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.

Insurance agent: *

Enter agents name.

Livestock Mortality Insurance Application

Animal Health Statement

FRAUD NOTICE – GENERAL WARNING

STATE SPECIFIC PROVISIONS