ABOUT THE POLICYHOLDER

Name of Policyholder *

Address

Occupation

Policy No *

Tel. No. *

Email

#beanshell.email#

DETAILS OF THE ANIMAL

Type of animal and breed *

Name and/or number *

Market value at time of death or injury

For what purpose was the animal used prior to its death or injury

Sex * -- Please Select -- Male Female

Age

Colour and any distinguishing marks *

DETAILS OF CIRCUMSTANCES

Date of the incident that caused the death or illness of the animal (s)

Where did it occur? *

Describe what happened *

In the case of death, what was the cause?

Where is the animal now? *

If the incident occured whilst the animal was in transit, was the vehicle being operated by a Livestock Haulier * -- Please Select -- Yes No

Please give name and address of haulier *

If you believe the incident was the fault of another party please state who, and why? *

Did a Vet attend the animal? * -- Please Select -- Yes No

When did the Vet first attend the animal? *

Name and address of the attending Vet *

Name of any witness to the incident, or the person who discovered the animal

Relationship of this person to the Policyholder
eg: employee, neighbour

DETAILS OF CLAIM

Was the animal home-bred * -- Please Select -- Yes No

When was it purchased?

What was the purchase price?

Have you received any payment for the value of the carcass? -- Please Select -- Yes No

How much? *

What was the market value of the animal at the time of its death?
You must provide an independent valuation to confirm the market value if the animal

How much are you claiming ?
(market value less any carcass value)

What was the total market value of all your livestock at the time of the incident

Is there any other insurance in force on the animal that would cover this incident * -- Please Select -- Yes No

Please give details *

Please insert here any other information that you wish to provide in connection with this claim

Veterinary Surgeon Report File

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DECLARATION

I/We declare that the information given on this form is true to the best of my/our knowledge and belief. I/We understand that information may be requested from other parties to check the information that has been given.

Signature

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