Newton Baker Insurance Services, Inc.
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PO Box 247, LAKEVIEW, NC 28350
U.S. & CANADA TOLL FREE 1-800-334-7733
FAX 1-800-874-3565
www.newtonbaker.com
We accept MasterCard, Visa, and American Express.
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VALUES 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. NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED AND SIGNED BY THE ASSURED AND VETERINARIAN.
THIS IS NOT A BINDER
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HORSE INSURANCE APPLICATION
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Name of Applicant:_________________________________________
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Effective Date:_______________
(Subject to receipt of satisfactory vet. cert. in CO's office.)
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Address:____________________________________________________________________________
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Business Phone:(____)______________
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Home Phone:(____)_______________
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NAME AND REGISTERED OR TATOO NUMBER
(Photos each side required on unregistered horses)
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Sex
(i.e. Colt, Gelding)
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Breed
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Use
(i.e. Hunter, Dressage)
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Date of Birth
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Date of Acquisition
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Acquired from Auction -Private
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Exact Purchase Price
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Amount of Insurance Desired
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USE REMARKS SECTION FOR ADDITIONAL COMMENTS
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YES
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NO
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1. Is there any other insurance applying to the animal listed?
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2. Does anyone else have an interest in the animal listed?
Please list interest, name and address:
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3. Is SURGICAL INSURANCE being applied for?
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4. Is MAJOR MEDICAL (includes surgical) being applied for?
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5. Is LOSS OF USE being applied for?
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6. Has any insurance company cancelled or declined similar insurance?
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7. Has the above listed animal been ill or injured in the past 2 years
including history of colic? Explain in remarks section.
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8. Has there been any contagious or infectious disease on your premises during the past year?
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9. Have any animal(s) in your care or ownership died in the past 3 years? If yes, please explain in remarks section.
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10. Have you any other horses not being insured? State number and why excluded.
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Name and address of your usual veterinarian.
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I declare the animal 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 contract, and if anything be falsely stated or information withheld to influence the company's decision, the insurance contract will be null and void. I designate this agent as the agent of record on the animal listed hereon.
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Signature of applicant________________________________________ Date application completed_______________
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For Office Use Only |
Binder#_____________
Rate Prem |
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| b.________________ |
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Credit Card # _______________________
3 Digit V Number_______
Card Holder Name____________________
Expiration Date______________
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Professionally We Serve ~ Personally We Care
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