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C. Jarvis Insurance Agency
LIVESTOCK MORTALITY APPLICATION

This form can be filled out online and printed when completed.
Once this form is completed please sign and fax to 440-248-8737

Christina Rousseau - Producer # 067

Click Here to download the application (pdf file)

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).

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

(1)

Applicant

(2)

Address

City

State

Country

Zip

(3)

Telephone

Days
Eves

PAYMENT OPTIONS

	Full Payment
	Payment Plan

Email Address

COVERAGE REQUIRED

	Full Mortality			$2,500 Surgical
	Specified Perils			$5,000 Surgical
	Loss of Use			$7,500 Surgical
	SPD			$5,000 Major Medical
				$7,500 Major Medical
				$10,000 Major Medical
	Other

12 MONTH EXTENSION

(Please choose and initial)
I Accept I Reject	the 12 Month Extension Endorsement on eligible horses at $25.00 per horse.
Initials:

A

Name of Horse or Pedigree If Unnamed	Reg. or Tatoo No.	Sex (e.g. Colt, Gelding, etc)	Breed

Use & Color	Date of Birth	Date of Acquisition	Auction or Private?

Stud Fee or Purchase Price	Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

B

Name of Horse or Pedigree If Unnamed	Reg. or Tatoo No.	Sex (e.g. Colt, Gelding, etc)	Breed

Use & Color	Date of Birth	Date of Acquisition	Auction or Private?

Stud Fee or Purchase Price	Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

C

Name of Horse or Pedigree If Unnamed	Reg. or Tatoo No.	Sex (e.g. Colt, Gelding, etc)	Breed

Use & Color	Date of Birth	Date of Acquisition	Auction or Private?

Stud Fee or Purchase Price	Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

D

Name of Horse or Pedigree If Unnamed	Reg. or Tatoo No.	Sex (e.g. Colt, Gelding, etc)	Breed

Use & Color	Date of Birth	Date of Acquisition	Auction or Private?

Stud Fee or Purchase Price	Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

E

Name of Horse or Pedigree If Unnamed	Reg. or Tatoo No.	Sex (e.g. Colt, Gelding, etc)	Breed

Use & Color	Date of Birth	Date of Acquisition	Auction or Private?

Stud Fee or Purchase Price	Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

F

Name of Horse or Pedigree If Unnamed	Reg. or Tatoo No.	Sex (e.g. Colt, Gelding, etc)	Breed

Use & Color	Date of Birth	Date of Acquisition	Auction or Private?

Stud Fee or Purchase Price	Amt. of Insurance Desired

APPLICANT MUST COMPLETE ALL QUESTIONS AND "SIGN" BELOW.
ANY QUESTIONS ANSWERED "YES" PLEASE EXPLAIN IN SPACE PROVIDED.

(4) Is there any other insurance applying to horse(s) listed?

No Yes

If "Yes", an explanation is REQUIRED.

(5) Does anyone else have any interest in the horses(s) listed? (include name & address)

No Yes

If "Yes", an explanation is REQUIRED.

(6) Has any insurance co. cancelled or declined similar insurance?

No Yes

If "Yes", an explanation is REQUIRED.

(7) Has any of the listed horse(s) had any illness, disease, lameness, injury, accident or physical disability in the past 2 years?

No Yes

If "Yes", an explanation is REQUIRED.

(8) Has there been any contagious disease on your premises during the past year?

No Yes

If "Yes", an explanation is REQUIRED.

(9) Have any horse(s) in your care of ownership died in the past 2 years?

No Yes

If "Yes", an explanation is REQUIRED.

10) Mare in foal?

No Yes

If "Yes", sire is REQUIRED.

to whom

STUD FEE

(11) Stallions:

A) Present stud fee

B) No. of bookings this season

C) No. of mares serviced last year

REMARKS / COMMENTS / SHOW RECORD

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.

FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

ALL OTHER STATES: 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, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties.

NOTICE: No animal will be bound for the full mortality until: a) This application has been property completed and received by this office; AND b) A current vet check covering such animals has been received by this office. Pending actual receipt of any such vet check, this office will bind coverage against Named Perils Only. c) Premium Payment with application - minimum payment is $150.00.

I declare the animal(s) as shown on the schedule to be in good health and condition and warrant the truth of the above statements. I agree this application shall be the basis of the contact and if anything be falsely stated or information withhold to influence the company's decision, the insurance contract will be null and void.

APPLICATION AND VET EXAM MUST BE IN OUR OFFICE
WITHIN 15 DAYS OF VET EXAMINATION DATE

Signature: ___________________________________________

Date: _______________________________________________

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___________________________________________________________

Contact

28429 N. 47th Street, Cave Creek, AZ 85331
(480) 794-1921 Office
(480) 907-1453 FAX

Dick Adams
Sales & Breeding Consultation
(805) 689-0876 Cell

Christina Rousseau
Promotion & Public Relations
(330) 419-0357 Cell
C. Jarvis Insurance Agent

Email: ContactSavannah@aol.com

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