Application

This is where the application should live. 
* All Cattle must be registered or branded.
Click on "Upload your files" button below to upload your Bill of Sale and Vet Certification documents.
    FRAUD NOTICES AND APPLICANT'S SIGNATURE

    STANDARD - Any person who knowingly and with intent to defraud any insurance company or other 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 hereto, commits a fraudulent act, which is a crime, and may subject such persons to criminal and civil penalties.

    NOTICE TO ARKANSAS APPLICANTS - Warning - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    NOTICE TO COLORADO APPLICANTS - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    NOTICE TO DISTRICT OF COLUMBIA APPLICANTS - 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 if false information materially related to a claim was provided by the applicant.

    NOTICE TO FLORIDA APPLICANTS - 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.

    NOTICE TO KENTUCKY APPLICANTS - Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

    NOTICE TO LOUISIANA APPLICANTS - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    NOTICE TO MAINE APPLICANTS - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

    NOTICE TO NEW YORK APPLICANTS - Any person who knowingly and with intent to defraud any insurance company or other 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 shall also be subject to a civil penalty not to exceed five thousand (5,000) dollars and the stated value of the claim for each such violation.

    NOTICE TO NEW JERSEY APPLICANTS - Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

    NOTICE TO NEW MEXICO APPLICANTS - ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

    NOTICE TO OHIO APPLICANTS - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

    NOTICE TO OKLAHOMA APPLICANTS - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

    NOTICE TO PENNSYLVANIA APPLICANTS - Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties.

    NOTICE TO TENNESSEE APPLICANTS - 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.

    NOTICE TO VIRGINIA APPLICANTS - 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.

    NOTICE TO WEST VIRGINIA APPLICANTS - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    I UNDERSTAND THAT THE SIGNING AND DELIVERY OF THIS APPLICATION DOES NOT BIND ME TO COMPLETE THE INSURANCE, NOR THE COMPANY TO ISSUE A POLICY: BUT EACH ANSWER GIVEN IN THIS APPLICATION IS A STATEMENT OF FACT THAT BECOMES A PART OF THE POLICY SHOULD A POLICY BE ISSUED. BY SIGNING THIS APPLICATION I ACKNOWLEDGE THAT I AM AWARE THAT IF AT ANY TIME IT IS DISCOVERED ANY OF THE STATEMENTS OF FACT CONTAINED IN THIS APPLICATION ARE CONCEALED OR FALSELY STATED, THE POLICY MAY BE MODIFIED, RESCINDED, OR DECLARED VOID FROM ITS INCEPTION AND IN ACCORDANCE WITH ANY APPLICABLE STATE LAWS.

    STATEMENT OF HEALTH

    I declare to the best of my knowledge that the animals named on this application are currently and have been in sound health and free from any injury, disease, lameness or disability of any kind. None of the animals listed on this application had any type of surgery and have not required treatment by a veterinarian for any injury, illness, disease, lameness or disability of any kind. All the animals named on this application are current on all vaccinations and boosters. If any cattle listed on this application has or had any defects, a completed veterinarian examination form must be completed unless the Company has provided written approval prior to binding any coverage.

    • Animal's Name and Registration Number/Branded Number *

    • Date of Birth

    • Sex

    • Breed

    • Exact Use

    • Acquired From Name/Address

    • Date Acquired

    • Purchased Price

    • Limit Desired