Alpaca Renewal Declaration of Health Form

APPLY FOR COVER BY COMPLETING THIS FORM
IF YOU ONLY REQUIRE A QUOTATION GO BACK AND SELECT THE ONLINE QUOTATION FORM

Fields marked * are mandatory

Your Details
*Full Name of Insured
*Client Reference
Alpaca Details
*Name
*Registration Number
*Colour
*Sex
*Year of Birth
*Use
*Sum Insured
*Insurance Option (Please refer to the Products page for more details)
Supreme CoverCrias
*Period of Insurance From (The insurance period should be a minimum of 12 months)
*To
*Payment Method
Credit Card (A charge of 2.5% will apply)
Cheque (Please send including the name of your alpaca on the reverse of the cheque)
Monthly payments available for premiums over $500 (We will email a funding agreement within the next 24 hours)
Direct Credit
*Are the above alpaca(s) at present normal in eye, wind and action to the best of your knowledge?
YesNo
*If No give details
*Have any of the above alpaca(s) suffered from colic or any other related illness at any time to the best of your knowledge?
YesNo
*If Yes give details
*Have any of the above alpaca(s) suffered from any illness, injury, disease or undergone any surgery at any time to the best of your knowledge? Do they have any blemishes?
YesNo
*If Yes give details
*Has there been any evidence of contagious or infectious disease during the past twelve months at the location(s) where the animal(s) are kept?
YesNo
*If Yes give details
*Have any of the above alpaca(s) been fired, blistered, nerved or received treatment for lameness (other than sore shins) at any time to the best of your knowledge or do any of the animal(s) have faulty conformation?
YesNo
*If Yes give details
*Have there ever been any instances of facial eczema at the locations where the above animal(s) are dept or will be kept?
YesNo
*If YES give details of when the outbreak occurred, how many animals were lost and give details of measures taken to prevent a re-occurrence?
*If any of the above are females, are any currently pregnant?
YesNo
If Yes, what was the last date of mating?
And the expected date of birth
view policy wording online
*I would like to receive the policy documents and invoice via email
YesNo
Click here to read the duty of disclosure
* I have read and understood my duty of disclosure
*Additional Cover (Stud Male Infertility)
YesNo

All information given in support of this proposal, whether oral or written is true and correct. I/We have disclosed to the underwriters all material facts required by law. If accepted, this proposal shall be the basis of the contract and incorporated in the Insurance Certificate. Underwriters reserve the right to place exclusions/warranties on any insurance issued on this application. Note: Any insurance certificate issued on this application will not cover any pre existing conditions of the animal(s) to be insured.

* I have read and agree to the terms and conditions
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