lkalmanson - Canine Mortality

AGENCY: LESTER KALMANSON AGENCY, INC &/OR MITCHEL KALMANSON

PO BOX 940008
MAITLAND, FL 32794-0008
PHONE: 407-645-5000
FAX: 407-645-2810
WWW.LKALMANSON.COM

NAMED INSURED

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ADDRESS

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CITY

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STATE

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ZIP

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PHONE

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CELL

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BUSINESS

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EMAIL

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TERM OF POLICY

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NEW

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RENEWAL OF

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RENEWAL OF

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EFFECTIVE DATE

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(AT 12:01 AM LOCAL STANDARD TIME)

COVERAGE DESIRED

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IS/ARE ANY ANIMAL(S) LEASED

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IF YES, ATTACH COPY OF LEASE

WITH WHOM ARE ANIMALS KEPT(OWNER/HANDLER/TRAINER)

GIVE NAME, ADDRESS, AND TELEPHONE NUMBER DETAILS ETC

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HAS ANY COMPANY CANCELED OR REFUSED TO RENEW YOUR COVERAGE

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IF YES, GIVE DATE AND REASON FOR ACTION(S)

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ARE YOU INSURING ANY OTHER CANINE(S) WITH ANOTHER COMPANY(S)

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IF YES, HOW MANY

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HOW ARE THEY USED (PROVIDE DETAILS)

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NAME, ADDRESS, TELEPHONE NUMBER & LICENSE NO. OF YOUR REGULAR VET

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HOW LONG HAVE YOU USED THIS VET

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YRS

MONTHS

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VALUES BASED ON

APPRAISAL

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PRIVATE PURCHASE

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SHOW

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POLICE TRAINING

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(STATE)

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OTHER (ATTACH JUSTIFICATION OF VALUE)

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ARE YOU THE SOLE OWNER

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IF NO, PLEASE INDICATE PARTIES & INTEREST

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ARE ANIMALS NOW INSURED

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PREVIOUSLY INSURED

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IF YES TO EITHER, WHAT COMPANY AND AMOUNT INSURED US$

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S C H E D U L E O F C A N I N E ( S ) T O B E
C O N S I D E R E D F O R I N S U R A N C E
* * * * * * * * * * * * * * * * * * * * * * * * * *

NAME OF ANIMAL / REG. #, TATOO# / BREED / SEX / D.O.B. / USE / PURCHASE PRICE &

MICROCHIP #

INSURED AMOUNT

1)

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2)

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3)

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4)

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5)

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**** IF INSURED AMOUNT IS DIFFERENT FROM PURCHASE PRICE PLEASE PROVIDE JUSTIFICATION OF VALUE

*IF OVER FIVE (5) CANINES PLEASE ATTACH SEPARATE SCHEDULE**

****CURRENT VETERINARIAN CERTIFICATE REQUIRED FOR FULL MORTALITY WHICH MUST BE DATED WITHIN 10 DAYS OF INCEPTION

D E C L A R A T I O N

IN MAKING APPLICATION FOR THIS INSURANCE, I/WE DECLARE THE ABOVE FACTS CONFIRM MY KNOWLEDGE AND ALSO THAT THIS INSURANCE HAS NOT BEEN REFUSED ELSEWHERE, NO OTHER INSURANCE IS IN EFFECT, OR THAT INSURANCE IS NOT IN EXCESS OF FAIR MARKET VALUE. I/WE DECLARE THAT I/WE ARE THE SOLE OWNER(S) OF THE ANIMAL(S) HEREIN DESCRIBED AND THAT THE SAME IS/ARE NOW IN SOUND AND GOOD CONDITION, AND THAT THERE IS NOT NOW, OR HAS THERE BEEN ANY CONTAGIOUS DISEASE IN MY/OUR VICINITY, AND THAT I/WE KNOW OF NO REASON WHY THIS INSURANCE SHOULD NOT BE GRANTED. NOTE: THIS APPLICATION IS MADE PART OF THE POLICY THAT IS ISSUED

PLEASE INITIAL AND DATE TO ACCEPT: (REQUIRED TO PROCESS APPLICATION)

INITIAL

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DATE

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HEALTH QUESTIONS ( TO BE ANSWERED BY INSURED)

DATE OF LAST HEARTWORM CHECK

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IS/ARE DOG(S) CURRENTLY ON HEARTWORM PREVENTATIVE

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HAS EACH DOG HAD EACH OF THE FOLLOWING VACCINATIONS

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MOST RECENT DATE GIVEN

DHL/DA2PL

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PARVO

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CORONA

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RABIES

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HAVE ANY OF YOUR DOGS EVER SEIZURED

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IF YES, EXPLAIN

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DO ANY OF THE DOGS HAVE COLLIE EYE, PRA OR CPRA

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PLEASE PROVIDE CERF (DOGS OVER 1 YEAR) & OFA ( DOGS OVER 2 YEARS)
NUMBERS FOR THE DOG(S) YOU ARE INSURING

CERF

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OFA

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HAVE DOG(S) EVER BEEN TREATED FOR ANY ACCIDENT, ILLNESS, OR LAMENESS

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IF YES, GIVE DATE AND DESCRIPTION OF TREATMENT

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REMARKS

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ANY PERSON WHO KNOWINGLY WITH THE INTENT TO INJURE, DEFRAUD, OR
DECEIVE ANY INSURANCE COMPANY OR OTHER PERSONS, FILES A STATEMENT OF
CLAIM CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE
OF MISLEADING, INFORMATION CONCERNING ANY FACT, MATERIAL THERETO,
COMMITS A FRAUDULENT ACT, WHICH IS A CRIME

PLEASE INITIAL AND DATE TO ACCEPT THE TERMS OF THE APPLICATION: (REQUIRED TO PROCESS APPLICATION)

INITIAL

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DATE

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AFTER SUBMITTING YOUR ONLINE APPLICATION

PLEASE DOWNLOAD, PRINT, AND SIGN THE "CANINE MORTALITY" SIGNATURE FORM

THIS FORM REQUIRES WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION

***CONFIDENTIALITY NOTICE: This message and any attachments are for the sole use of the intended recipient(s) and may contain confidential and privileged information that is exempt from any public disclosure. Any unauthorized use, review, disclosure, or distribution is prohibited. If you have received this message in error, please contact the sender by phone or electronic mail, and destroy all copies of this message.***

captcha(*)

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CANINE MORTALITY INSURANCE APPLICATION

AGENCY: LESTER KALMANSON AGENCY, INC &/OR MITCHEL KALMANSON

(AT 12:01 AM LOCAL STANDARD TIME)

IF YES, ATTACH COPY OF LEASE

WITH WHOM ARE ANIMALS KEPT(OWNER/HANDLER/TRAINER)

S C H E D U L E O F C A N I N E ( S ) T O B E C O N S I D E R E D F O R I N S U R A N C E * * * * * * * * * * * * * * * * * * * * * * * * * *

**** IF INSURED AMOUNT IS DIFFERENT FROM PURCHASE PRICE PLEASE PROVIDE JUSTIFICATION OF VALUE

*****IF OVER FIVE (5) CANINES PLEASE ATTACH SEPARATE SCHEDULE******

****CURRENT VETERINARIAN CERTIFICATE REQUIRED FOR FULL MORTALITY WHICH MUST BE DATED WITHIN 10 DAYS OF INCEPTION

PLEASE INITIAL AND DATE TO ACCEPT: (REQUIRED TO PROCESS APPLICATION)

HEALTH QUESTIONS ( TO BE ANSWERED BY INSURED)

AFTER SUBMITTING YOUR ONLINE APPLICATION

PLEASE DOWNLOAD, PRINT, AND SIGN THE "CANINE MORTALITY" SIGNATURE FORM

THIS FORM REQUIRES WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION

S C H E D U L E O F C A N I N E ( S ) T O B E
C O N S I D E R E D F O R I N S U R A N C E
* * * * * * * * * * * * * * * * * * * * * * * * * *

*IF OVER FIVE (5) CANINES PLEASE ATTACH SEPARATE SCHEDULE**