jarvisinsurance.com - Livestock Mortality Application

NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED AND SIGNED BY THE APPLICANT.

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Applicant*

First Name

Last Name

Email Address*

Address Type*

United States Address
P.O Box
International

Address

City

State/Province

ZIP / Postal

Country

P.O. Box

Please enter the address for your P.O. Box

International Address

Please enter your full international address.

Phone Number - Days*

Cell Phone

Fax

Payment Options*

Full Payment Payment Plan

Save and Resume Later

Progress

Save and Resume Later

Progress

VALUES OTHER THAN THE PURCHASE PRICE ARE SUBJECT TO ACCEPTANCE BY THE COMPANY. DETAILS OF PRIZE WINNINGS, PERFORMANCE, SERVICE FEE, NUMBER OF BOOKINGS AND OTHER PERTINENT INFORMATION MUST BE SUBMITTED FOR CONSIDERATION OF STATED VALUES
(Use Below for Details).

REMARKS / COMMENTS / SHOW RECORD

If a veterinary examination form is required, it must be dated and received within 10 days of this application.

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 may subject such person to criminal and substantial civil penalties.

I declare to the best of my knowledge and belief that the horse(s) listed on the above application to be in normal healthy sound condition. I further declare that during the past twelve (12) months the above listed horse(s) have been free from any ILLNESS, INJURY, DISEASE, or ACCIDENT. 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 also understand that it is required under the policy to give IMMEDIATE notice by telephone of any illness, injury, disease or death of any insured horse. Not doing so may jeopardize coverage and result in denial of any claim made.

I confirm no similar insurance has ever been declined or cancelled. I understand and agree that the policy to be issued shall be founded upon the statements contained herein, and this statement shall be the basis of the contract, and if anything be falsely stated or information withheld, the insurance shall be null and void.

I have read and agree to the above.

Would you like to receive information about Private Horse Owners Liability?*

Yes No

Would you like to receive information about Farm, Ranch, or other Liability Coverage?*

Yes No

Would you like to receive your policy invoices and documents electronically?*

Yes No

Electronic Signature*

Horse 1 Information

Horse 1 Additional Coverage

Horse 2 Information

Horse 2 Additional Coverage

Horse 3 Information

Horse 3 Additional Coverage

Horse 4 Information

Horse 4 Additional Coverage