The Hartford Insurance Quote

Applicant's Name

Agency Code

Address

City

State

Zip

Phone*

Email*

Proposed Effective Date:

(coverage begins on the date of acceptance by the company)

Installment Payment Plans?

Yes
No

(Available on Premiums over $500)

Animal Name

Date of Birth

Date of Purchase

Purchase Price

(or stud fee if raised)

Requested Limit of Insurance

Identification

(Sire/Dam, Registration#, Tattoo#, or Pictures if unregistered)

sex

(Male, Female or Neutered)

Species

Breed

Use

Primary Housing Location:

Type of Coverage Requested:

Mortality-Full
Mortality-Limited
Third Choice

Will the animal be observed and cared for daily?

Yes
No

If no, explain:

Has animal listed received treatment for an accident, injury, sickness, disease, lameness or bloat in the last 12 months?

Yes
No

If Yes, provide complete details including occurrence date(s)

Other than for routine care, is the animal listed receiving regular treatment, medication or supplements?

Yes
No

If Yes, please explain:

Will the animal be transported during the coverage period?

Yes
No

Is the animal due to give birth any time during the requested Policy Period?

Yes
No

If Yes, please give:

Estimated Birthing Date:

Number of previous births:

Please enter a number greater than or equal to 0.

Breeding fee:

Has the animal listed suffered from a prolapsed uterus or experienced any other birthing difficulties?

Yes
No

If Yes, please provide details below.

Has there been any illness, injury or death to any other animal owned by you in the past 36 months that were covered by mortality insurance or not?

Yes
No

If Yes, please provide details below.

Has there been any evidence of contagious or infectious disease during the past twelve months in the location where the animal is kept?

Yes
No

If Yes, please provide details below.

Has any insurance carrier ever canceled, non-renewed or refused to insure any animal in which the applicant has or had an insurable intrest?

Yes
No

If Yes, please provide details below.

Is there any other insurance on the animal?

Yes
No

If Yes, provide the carrier name:

Expiration Date:

Amount of coverage

Is the animal listed leased to others?

Yes
No

If Yes, please attach a copy of the Lease Agreement

Max. file size: 10 MB.

Is there a Loss Payee?

Yes
No

If Yes, Name:

Address:

Are you the sole owner of the animal?

Yes
No

If No, provide owners % of interest:

Other owners Name:

Other owners address:

Licensed Veterinarian Information

Email:

Address:

Cell Phone:

Do you understand that the insurance policy you are applying for requires you to give the Company immediate notice of any covered animal's death, injury , or disease, along with a description of the condition and the name of the attending veterinarian? Do you also understand that failure to give this immediate notice may result in the denial of a claim?

Yes
No

NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY NE COLLECTED FROM PERSONS OTHER THAN YOU IN-CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT, or WA; in LA, ME, TN and VA, insurance benefits may also be denied)

IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IFFALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

IN 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

IN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THERE OF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AND APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERE TO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERE TO COMMITS A FRAUDULENT INSURANCE ACT.

IN MASSACHUSETTS, NEBRASKA, OREGON, AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THERE TO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.

IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. pENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.