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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Horse Mortality Insurance
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Name:__________________________________
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Effective Date:_____________
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Address:__________________________________________________________
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City:_______________________ State:___________ Zip:__________
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Business Phone:( ___)___________
Home Phone:(____)___________
Fax:(____)___________
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To order coverage, kindly COMPLETE, SIGN AND DATE this certificate, after reading the statement of condition carefully. This certificate must be returned before coverage is effective.
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THIS FORM APPLIES FOR ANIMALS TO BE INSURED FOR $25,000 OR LESS AND 31 days-12 YEARS OF AGE.
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Name of Animal
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Sex
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Breed
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Use (i.e. Hunter, Breed)
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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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FOR ADDITIONAL PREMIUM QUOTED DO YOU DESIRE:
SURGICAL: Yes____ No____ MAJOR MEDICAL: Yes____ No____
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- Is there any other insurance applying to the animal(s) listed? Yes____ No____
- Does anyone else have an interest in the animal(s) listed? Yes____ No____
Please list interest, name and address:___________________________________________
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STATEMENT OF CONDITION
* FOR ANIMALS VALUED AT $25,000 OR LESS.
Please sign and date, where indicated below, after carefully reading the following Statement of Condition.
To the best of my/our knowledge and belief, the animal(s) that is/are the subject of this application is/are now in sound and healthy condition and has/have not required the care of a veterinarian for any illness or injury during the past 12 months. Furthermore, at the present time, the animal(s) is/are not suffering from any type of chronic or acute condition for which veterinarian medical attention has been sought, such as Laminitis, Navicular Disease, Arthritis, Neurological Disorders, Heaves, Emphysema, Bleeding Tying Up, Colic or Intestinal Disorders, or any other type of equine malady. I/We 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 to influence the company's decision, the insurance shall be null and void.
SIGNATURE OF INSURED___________________________________ DATE_______________
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For Office Use Only |
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Rate Prem |
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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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