Newton Baker Insurance Services, Inc.

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.

Horse Mortality Insurance Renewal Application

Name:__________________________________

Phones: (Day)______________(PM)______________

Address:__________________________________________________________

City:______________________ State:___________ Zip:__________

Dear Insured:
Effective date of renewal is____________. To order your renewal coverage, kindly COMPLETE, SIGN AND DATE this certificate, after reading the Statement of Condition carefully. This certificate MUST be returned prior to the expiration of the policy.

THIS RENEWAL FORM APPLIES ONLY TO ANIMALS INSURED FOR $50,000 OR LESS

NAME OF ANIMAL	BREED	YEAR OF BIRTH	SEX	USE	LIST INNOCULATIONS INCLUDING DATES	HOW OFTEN DEWORMED LAST DATE	INSURANCE AMOUNT
A.
B.
C.
D.

FOR ADDITIONAL PREMIUM QUOTED,
DO YOU DESIRE:

SURGICAL INSURANCE Yes____ No____
MAJOR MEDICAL Yes____ No____
LOSS OF USE Yes____ No____

Credit Card # _______________________
3 Digit V Number_____________________
Card Holder Name____________________
Expiration Date_______________________

USE THIS SECTION FOR ADDITIONAL COMMENTS

STATEMENT OF CONDITION
* FOR ANIMALS VALUED AT $50,000 OR LESS.
Please sign and date, where indicated below, after carefully reading the following Statement of Condition. Return this form to our office prior to expiration date or a new veterinary certificate will be required to renew.
To the best of my/our knowledge and belief, the animal(s) that is/are the subject of this renewal notice 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 policy period. 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_________________

For Office Use Only

Rate Prem

a. _______________

b.________________

c.________________

It has been our pleasure to serve you for the past year. We encourage your call at our toll free number for any questions concerning your renewal.

Professionally We Serve ~ Personally We Care

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