Fillable PASTURE CATTLE APPLICATION (Standard Lines Services)

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PASTURE CATTLE APPLICATION (Standard Lines Services)

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THE HARTFORD - LIVESTOCK DEPARTMENT
www.hartfordlivestock.com
(800)-295-1815
PASTURE CATTLE 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:
Inspection Contact
Phone
( ) -
Type of Coverage Requested: Optional Endorsement(s) Requested:
Livestock Feeding and Growing Facility
Livestock Transit (attach Transportation Application)
Special Drowning Coverage Theft Exclusion
Livestock Born At Listed Locations
Other
What type of reporting period/payment option is desired: Monthly (2 month deposit required) Seasonal Other
Deposit amount attached: $
Deductible requested: $ per occurrence.
Are there any animals at any listed location(s) that are not included in this application? Yes No If Yes, explain:
Description of Covered Livestock
Location
No.(s)
Section
No.
Township
No.
Range
No.
County
**Type
of Cattle
Brand
Per
Head
Weight
No. of
Head
Avg. Value
Per
Animal
Rate Premium
Total Premium
**TYPE – INDICATE IF STEER (S), HEIFER (H), COWS (C), BULLS (B) OR CALVES (CV)
(Distance) (Direction) (Distance) (Direction) (Town), (State)
Location 1
Miles and Miles from ,
Location 2 Miles and Miles from ,
Location 3 Miles and Miles from ,
Location 4 Miles and Miles from ,
Location 5 Miles and Miles from ,
1. Source of Cattle: 2. Breed of Cattle:
3. Is pasture owned or leased by applicant? (if leased, please provide Lessor’s name, address and phone)
4. Is it grass pasture? Yes No 5. Is pasture Public Domain? Yes No
6. Does the property contain any rivers, streams, large dams or dry washes? Yes No If Yes, describe:
7. What is the source of water?
8. Does applicant have water quality analysis performed on a regular basis? Yes No
If Yes, how frequently and for what results?
Page 1 of 3 ©, Hartford Fire Insurance Company, 2007 LS 16 15 08 07
87-
9. List all equipment that is available on premises to take care of and feed cattle in the event of a storm:
10. Is any of the equipment used in feeding out of pen cattle used for any other purpose? Yes No If Yes, for what purpose?
11. What is the source of supplemental feed? 12. What type of feed is it?
13. Does applicant provide supplemental feed at the out of pen locations? Yes No If Yes, approximately what percentage of
the total feed supply is it?
14. Estimated number of days supplemental feed on hand:
15. Are feeders/feed bunks cleaned thoroughly before a different group of cattle are moved into a pasture? Yes No
If No, explain:
16. Who resides on the premises? Applicant Manager Hired Help Other
17. Does applicant personally supervise or attend the cattle? Yes No 18. Are there shelters and/or windbreaks? Yes No
19. How often are the cattle checked? 20. Is the pasture easily accessible by road? Yes No
21. Loss Payee(s): (Name and Address)
22. Licensed Veterinarian to be used on claims (Name, address and phone number):
23. Does applicant own, operate or have financial interest in any other similar operation? Yes No If Yes, explain:
24. Does the applicant currently have any outstanding judgments or past due accounts? Yes No If Yes, explain:
25. Has applicant ever been canceled or nonrenewed by an insurance company? (Not applicable in MO) Yes No If Yes, explain:
LOSS HISTORY. Please list all losses sustained in the last five years:
Date of Loss
Cause of Loss Amount of Loss
DO YOU AGREE TO
1. Notify the Agent or Company immediately and not later than 24 hours after a loss?..............................
Yes No
2. Not to move cattle from point of death, until authorized by us, unless legally required to do so? ...........
Yes No
3. Provide a certificate at your expense, stating the cause of death signed by a licensed veterinarian?....
Yes No
4. Notify the Agent or Company within 48 hours of movement of the cattle to a different county?..............
Yes No
"Insurance on pasture cattle shall expire at 12:01 a.m. on the day of 20 .
"The premium is fully earned on the date of inception of this policy.
"Coverage shall not become effective sooner than 24 hours after this application has been signed by both applicant and agent.
Please Attach Diagram Of Location(s) Showing Any Structures And Windbreaks.
Page 2 of 3 ©, Hartford Fire Insurance Company, 2007 LS 16 15 08 07
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 3 of 3 ©, Hartford Fire Insurance Company, 2007 LS 16 15 08 07
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PASTURE CATTLE APPLICATION (Standard Lines Services)

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Completed 7 February 2021

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