Fillable LIVESTOCK MARKET APPLICATION (Standard Lines Services)

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LIVESTOCK MARKET APPLICATION (Standard Lines Services)

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THE HARTFORD - LIVESTOCK DEPARTMENT
www.hartfordlivestock.com
(800)-295-1815
LIVESTOCK MARKET APPLICATION
Producer’s Name
Applicant’s Name
Agency Code
Mail Address
Mail Address
City, ST Zip
,
City, ST Zip
,
Phone
( ) -
Phone
( ) -
Fax
( ) -
Fax
( ) -
E-mail Address
E-Mail Address
Individual
Partnership
Corporation
Joint Venture
Limited Liability Corporation
Other
Year Business Started
Proposed Effective Date: Rate(s): Agency Bill Direct Bill
Inspection Contact:
Phone: ( ) -
Location of Premises: Protection Class Rating:
Type of Coverage Requested: Optional Coverage Form Requested:
TRANSIT PREMISES
Mortgaged and Stolen Livestock
Livestock Transit Coverage Form Livestock Premises Coverage Form
Other
(Limited Named Peril LS 00 21) (Limited Named Peril LS 00 23)
Livestock Transit Coverage Form Livestock Premises Coverage Form
Optional Endorsement(s) Requested:
(Broad LS 00 20) (Broad LS 00 22)
Are P & S Bonds required with this application? Yes No If Yes, attach Livestock Bond Application
1. (a). Does applicant receive animals from any of the following states? Yes No If Yes, please indicate which states:
Alabama Maine Montana New Mexico Oregon Vermont
Colorado Minnesota Nebraska North Dakota South Dakota West Virginia
Idaho Mississippi New Hampshire Oklahoma Utah Wyoming
Louisiana
(b). Has applicant registered with the Central Filing System of such state(s), and does applicant regularly receive Notices
of Livestock Liens?
Yes No If No, please explain: _____________________________________________
(c). Has applicant established office procedures to properly process the Notices of Livestock Liens? Yes No
If No, please explain:
________________________________________________________________________
2. Specify all methods of marketing at this location:
(a) Auction
Please provide sale day schedule:_______________________________________________________________
Approximate number of animals handled per week:
Cattle Hogs Sheep Horses and/or Mules
(b) Special Sales Auction Private Sale
Number of animals sold annually: Cattle Other (specify)
3. Are there any special valued animals sold at this market? Yes No If Yes, please explain:
4. Is there any long term feeding? Yes No If Yes, please explain:
5. What is the approximate number of miles that animals are hauled to reach applicant’s market? __________________
_
6. What is the approximate length of time that animals remain on applicant’s premises after arrival? ________________
_
Attach Diagram And Photos Of Market Showing Locations Of All Structures.
Page 1 of 2 ©, Hartford Fire Insurance Company, 2005 LS 16 11 01 05
7. What is the construction type of the yards? Wood Metal Concrete Other _________________________
_
8. Describe the loading and unloading facilities:
9. Will all outside gates be locked when not in use?
Yes No
10. Describe any other security measures currently in place:
11. Does the arrangement of pens and alleys allow for proper access to exits for the removal of animals in the event of
fire or other emergency? Yes No If No, explain:
• What is the number of exits?
12. Describe any combustible exposures and their location on the premises:
13. Number of miles from responding fire department:
14. Loss Payee(s):
(Name and Address)
15. Does the applicant own, operate or have financial interest in any other similar operation?........................... Yes No
16. Does the applicant have any other insurance with The Hartford? ...........................................................
Yes No
17. Name of current livestock market insurance carrier: Policy Number:
18. Has the applicant ever been canceled or nonrenewed by an insurance company? (Not applicable in MO) ....................... Yes No
19. Please provide a five year loss history:
Year Premium Amount of Losses
If Yes to question(s) 15, 16 or 18, please explain:
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or
broker for your state’s requirements.)
NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY
BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY
RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN
CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR
PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR
RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR
INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER
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 THE PERSON
TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.
(Not applicable in CO, HI, NE, OH, OK, OR, or, VT; in DC, LA, ME, TN, and VA, insurance benefits may also be denied. See below for additional Fraud Warnings)
APPLICANTS SIGNATURE DATE PRODUCERS SIGNATURE DATE
Applicable in Colorado
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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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.
Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she 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.
Applicable in Oklahoma
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.
Applicable in Nebraska, Oregon and Vermont
Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a crime.
Page 2 of 2 ©, Hartford Fire Insurance Company, 2005 LS 16 11 01 05
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LIVESTOCK MARKET APPLICATION (Standard Lines Services)

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Completed 7 February 2021

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