Insurance Dog Form

Insurance Dog Form

Applicant Name:     Date of Birth:     Phone:

Dog Information

Dog Name:     Breed:     Color/Markings:

Date of Birth or Age:     Sex:     Microchip Number:

Licensed with Municipality:     Spayed/Neutered: Yes    No

Clinic Phone:     Last Examination Date:

Policy Details

Accident & Illness    Accident Only    Wellness Preventive Care    Third-Party Liability

Coverage Limit: $     Deductible: $     Annual Premium: $

Policy Period From:     To:

Optional Coverages

Theft/Straying    Board & Care Fees    Behavioral Therapy (court-ordered or prescribed)    Elective Procedures (specified)

Medical & Prior History

Previously Insured: Yes    No

Claims & Documentation Checklist

At time of claim submission, the following are required (check all provided):
Veterinary clinical report dated and signed
Itemized invoices and proof of payment
Photographic evidence of injury or loss (if applicable)
Police report (required for theft)

Exclusions — Applicant Acknowledgement

The policy does not provide coverage for the following items unless expressly endorsed. Applicant must initial each item to indicate acknowledgement and understanding.

Initials: Pre-existing conditions, congenital or hereditary disorders.

Initials: Cosmetic or elective procedures not medically necessary.

Initials: Breeding, pregnancy, whelping, or related conditions.

Initials: Injury sustained during intentional or unlawful acts by the insured.

Initials: Loss or injury caused by war, civil insurrection, or government seizure.

Payee / Beneficiary for Claim Payment

Authorization, Representations and Certification

By signing below, the Applicant certifies that all statements and answers contained in this form are true, complete and correct to the best of the Applicant's knowledge. The Applicant understands that any material misrepresentation or omission in this application may be treated as fraudulent and may result in denial of coverage, rescission of the policy, or forfeiture of benefits pursuant to the insurer's contractual rights and applicable law.

The Applicant authorizes any veterinarian, hospital, insurer, or other relevant business or professional to release to the insurer any records or information regarding the dog's medical history, treatments, vaccinations and billing necessary to evaluate coverage eligibility or process claims. This authorization is valid for the purposes of underwriting, evaluation of claims, and fraud investigation. A copy of this authorization shall be as valid as the original.

The Applicant agrees that coverage is subject to the policy terms, conditions, limits and exclusions. The Applicant acknowledges that cancellation, non-renewal, premium adjustments, and claims handling practices will be governed by the policy issued and any applicable statutory requirements. The Applicant further acknowledges the insurer's subrogation rights and agrees to cooperate with the insurer in the pursuit of recovery from third parties responsible for covered loss.

Any person who knowingly presents false information in an attempt to obtain insurance benefits may be subject to penalties including denial of benefits, civil damages, fines, and criminal prosecution under applicable law. The Applicant affirms that the information provided in this application is correct and complete.

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