APPLICATION FOR INSURANCE WITH AMERICAN LIVE STOCK INSURANCE COMPANY
I/WE 
of   
hereby apply for insurance against loss by death resulting from disease or accidental injuries for the term of on the following described animal or animals:

Name of Animal
Registration and/or Tattoo Number
Breed
Use
Sex
Birthdate
Purchase Price
Purchase Date
Amount of Insurance
Rate
Premium
 

• Veterinary certificates must be current within 14 days of inception.
• Purchase price must be actual cash price paid at the time of purchase.


Values based on:      
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.
I hereby certify that I have this day examined the aforementioned animal(s).
I have witnessed locomotion and observed no defects or unsoundness of limb.
I know of no record of illness in the past 12 months.
I know of no record or indication of sterility, past or present.
I would consider the animal(s) sound and normal in every other respect.
Get Adobe Reader

Copyright 2008 Breeder's Insurance. All rights reserved.

Website by Ignyte Software