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THE HARTFORD
LIVESTOCK DEPARTMENT
www.hartfordlivestock.com
(800)-295-1815
(Minimum Earned Policy Premium $250.00)
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
Policy Term Desired (maximum term 12 months):
Individual Partnership Corporation Joint Venture Limited Liability Corp. Other
Proposed Effective Date: New Policy
(Coverage begins on the date of acceptance by the Company) Endorsement (Policy Number)
Installment Payment Plans? Yes No
(Available on Premiums over $500)
Animal Name Date of Birth Date of Purchase Purchase Price Requested Limit of Insurance*
Identification (Registration#, Tattoo#, Microchip# or Pictures if unregistered) Sex (Bull, Cow, Heifer, Steer) Breed Use
Primary Housing Location:
All Limits of Insurance are subject to company approval.
*For a Requested Limit of Insurance that does not equal the Purchase Price, complete and attach a Substantiation of Value.
Type of Coverage Requested:
Mortality - Full Mortality - Limited Aggregate Deductible Other __________________
1.
Will the animal be observed and cared for daily? If No, please explain:
Yes No
2.
Has animal listed received treatment for an accident, injury, sickness, disease, lameness, displaced abomasum or bloat in th
e
last 12 months? If Yes, provide complete details including occurrence date(s).
Yes No
3.
Other than for routine care, is the animal listed receiving regular treatment, medication or supplements?
If Yes, please explain:
Yes No
4. Will animal be transported during the coverage period? Yes No
5.
Is the animal due to calve any time during the requested Policy Period?
If Yes, please give:
Estimated Calving Date:
Bred to: Number of Previous Calves:
Yes No
6.
Has the animal listed suffered from a prolapsed uterus or experienced any other birthing difficulties?
If Yes, please provide details below.
Yes No
7.
Has there been any illness, injury or death to any other cattle owned by you in the past 36 months that were covered by
mortality insurance or not? If Yes, please provide details below.
________________________________________________________________________________________
Yes No
8.
Has there been any evidence of contagious or infectious disease during the past twelve months in the location where
the animal is kept? If Yes, please explain:
__________________________________________________________________________________________
Yes No
9.
Has any insurance carrier ever canceled, non-renewed or refused to insure any animal in which the applicant has or had an
insurable interest? If Yes, provide details:
__________________________________________________________________________________________
Yes No
10.
Is there any other insurance on the animal listed?
If Yes, name of current insurance carrier:______________________________________________________________
Expiration Date:
Amount of coverage: _______________________
Yes No
11. Is the animal listed leased to others? If Yes, please attach a copy of the Lease Agreement. Yes No
Page 1 of 3 ©The Hartford, 2011 LS 16 24 12 11
Jan 03, 2012
ANIMAL MORTALITY APPLICATION
for Cattle
12.
For animal listed is there a Loss Payee:
(Name and Address) _______________________________________________________________________________
Yes No
13.
Are you the sole owner of the animal? If No, provide other owner’s % of interest, name and address:
________________________________________________________________________________________________
Yes No
14.
Name, address, and telephone number of the animal’s primary licensed Veterinarian:
________________________________________________________________________________________________
15.
Do you understand that the insurance policy you are applying for requires you to give the Company immediate notice of any
covered animal’s death, injury, sickness, or disease, along with a description of the condition and the name of the attending
veterinarian? Do you also understand that failure to give this immediate notice may result in the denial of a claim?
Yes No
For Bucking Bulls Only:
1.
Has any animal been given anabolic steroids or any other substance with or without your knowledge?
If Yes, provide details:
Yes No
2.
Has any animal ever tested positive for anabolic steroids or any other substance?
If Yes, please explain and provide test results.
Yes No
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 MAY BE COLLECTED FROM PERSONS OTHER
THAN YOU INCONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND
PRIVILEGED INFORMATION COLLECTED BY USOR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEWYOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST
CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS ANDOUR PRACTICES REGARDING SUCH
INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMITA REQUEST
TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON
FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION,
OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY:
SUBSTANTIAL] CIVILPENALTIES.
(Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance
benefits may also be denied)
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR
THE PURPOSE OF DEFRAUDINGTHE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN
ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IFFALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS
PROVIDED BY THE APPLICANT.
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR ANAPPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY OF THE THIRD DEGREE.
IN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE ORBELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF,OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF,
OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR ACLAIM FOR PAYMENT OR OTHER
BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS
TOCONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE
OF MISLEADING, INFORMATIONCONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY ORANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING
ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FORTHE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BEA CRIME AND MAY SUBJECT
THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OFDEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF
INSURANCE BENEFITS.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY
HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS
ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HERKNOWLEDGE.
APPLICANTS SIGNATURE DATE (Must be no more than 30 days prior to policy effective date)
PRODUCERS SIGNATURE PRODUCERS NAME(Please Print) STATE PRODUCER LICENSE NO.
(Required in Florida)
Page 2 of 3 ©The Hartford, 2011 LS 16 24 12 11
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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
I, hereby certify that I have this day of examined the following animal at rest and in motion:
(Please Print Name)
Animal Name:
1. How long have you been the veterinarian for the above animal?
2. a. Do both eyes of the animal appear clinically normal without drainage?............................................................. Yes No
b. Do the lungs and heart sounds fall within normal ranges?.................................................................................
Yes No
c. Does the hair coat appear to be smooth and shiny?..........................................................................................
Yes No
d. Have you examined the animal without the aid of chemical restraint?...............................................................
Yes No
d. Do the feet appear to have normal growth? .......................................................................................................
Yes No
e. Does the animal appear relaxed and free of pain in all gaits/movements observed?.........................................
Yes No
f. Is herd free of Bruccellosis? .........................................................................................................................
Yes No
g. Is the animal routinely wormed or vaccinated? ..................................................................................................
Yes No
If “No” to any of the above, please give details.
3. a. Does there now exist, or has there recently been any infectious disease in animals area?............................... Yes No
b. Does the animal have any physical deformities, disease, or infection?..............................................................
Yes No
c. Does the animal examined show any symptom of previous sickness, disease, or injury?.................................
Yes No
d. Does the animal receive any other medication?.................................................................................................
Yes No
e. Does the animal exhibit any respiratory or circulatory distress? ........................................................................
Yes No
f. Are there any signs of lameness and/or incoordination?....................................................................................
Yes No
If “Yes”, to any of the above, please give details.
4. Please give a brief history of any major surgery and/or treatment for disease or injury you have performed on the animal
listed during the last year
Bulls Only: Cows Only:
1. Do genitals appear healthy and normal?............... Y N 1. Is cow free of mastitis? ......................................... Y N
2. Does penis and prepuce appear normal and free of any 2. Is the cow bred? ................................................... Y N
sores, infection, tumors or injury? ......................... Y N Est Calving Date:
3. Are testicles of normal dimension and consistency and fully 3. Is there any history of gestation, lactation or
distended into scrotum?........................................ Y N parturition problems?............................................ Y N
Detail any abnormal findings:
Detail any problems or concerns:
Veterinarian’s Signature Date Telephone Number
Veterinarian’s Address:
Page 3 of 4 ©The Hartford, 2011 LS 16 24 12 11
V
ETERINARIAN’S STATEMENT OF EXAMINATION FOR CATTLE
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Completed 7 February 2021

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