APPLICATION FOR INSURANCE WITH AMERICAN LIVE STOCK INSURANCE COMPANY 

I /We______________________________________________________________

_____________________________________________________________________________________
Address                                                             Zip Code                                   Telephone

hereby apply for insurance against loss by death resulting from disease or accidental injuries 
for the term of __________________ on the following described animal or animals:

Name of Animal Registration and/or Tattoo Number 

Breed

Sex

 Birth Date Purchase Price

Purchase Date

 Amount of
Insurance		 Rate Premium
               
               
               
               
               
               
               

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 in excess of fair market value. I/We declare that I/we are the sole owner of the animal(s) herein described and that same is now in sound and good condition; and that there is not now, nor 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.

Values based on:
Appraisal _________ Private Purchase_________ Auction Purchase_________ 
Use Examples – Breeding, Racing, Jumping, Show, Cutting, Pleasure.

____________________________________________________________________________________________________
Signature of Applicant                                                                                                                                Date

Print - then Fax or Mail to Jame Secondino
20860 Clinton Rd.  Paris, IL 61944
Phone  - 765-832-2697 - Fax 765-832-9185

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