lkalmanson - Exotic Mortality

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

POST OFFICE BOX 940008
MAITLAND, FLORIDA U.S.A. 32794-0008
PHONE: 407-645-5000 FAX: 407-645-2810
www.lkalmanson.com

I M P O R T A N T

T H I S I S N O T A B I N D E R .

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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BUSINESS

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FAX

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EMAIL

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PROPOSED EFFECTIVE DATE

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CONSIGNEE / LESSEE

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LOSS PAYEE(S)

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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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SOLE AUTHORITY FOR INSURED

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MODE OF TRANSPORTATION

LAND

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AIR

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SEA

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RAIL

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COVERAGE DESIRED

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select

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IF OTHER

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VALUE OF ANIMAL(S) BASED ON

APPRAISAL

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PRIVATE PURCHASE

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AUCTION PURCHASE

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LEASE / LOAN AMOUNT

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OTHER (ATTACH JUSTIFICATION OF VALUE)

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COMMENTS / REMARK(S)

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NAME: COMMON / SCIENTIFIC / ANIMAL I.D. / BAND / TAG / TATOO / REGISTRATION / MICROCHIP / COLOR /ETC

A)

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B)

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C)

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D)

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IF TRANSIT COVERAGE IS INCLUDED, PLEASE PROVIDE FULL DETAILS (IE. TYPE OF CRATING, BY TRUCK / AIR INCLUDING FULL FLIGHT DETAILS, ETC)

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BREED / SPECIES AGE D.O.B. SEX INTENDED USE

A)

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B)

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C)

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D)

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PURCHASE DATE PURCHASE PRICE REQUESTED INSURED AMOUN

A)

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B)

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C)

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D)

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RATE

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PREMIUM: $

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NO CLAIMS BONUS

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DEDUCTIBLE: $

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/ PER

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ANY PRIOR LOSSES

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IF YES, GIVE DETAILS

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* CURRENT VETERINARIAN CERTIFICATE REQUIRED FOR FULL MORTALITY *

* WHICH MUST BE DATED WITHIN 7 DAYS OF INCEPTION *

D E C L A R A T I O N ( S )

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(S) OTHER
THAN INDICATED. 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(S) WHY THIS INSURANCE SHOULD NOT BE GRANTED. NOTE: ANY PERSON WHO
KNOWLINGLY 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.

PLEASE INITIAL AND DATE TO ACCEPT TERMS OF 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 "EXOTIC 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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MORTALITY INSURANCE APPLICATION

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

*** CURRENT VETERINARIAN CERTIFICATE REQUIRED FOR FULL MORTALITY ***

*** WHICH MUST BE DATED WITHIN 7 DAYS OF INCEPTION ***

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

AFTER SUBMITTING YOUR ONLINE APPLICATION

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

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

* CURRENT VETERINARIAN CERTIFICATE REQUIRED FOR FULL MORTALITY *

* WHICH MUST BE DATED WITHIN 7 DAYS OF INCEPTION *