Insurance Form

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It is now required that all animals hauled on livestock charters are insured for mortality. Please complete the following information on each animal you are shipping.

Name	Age	Sex	Breed	Reg No.	Value

The value indicated above is based on:

Appraisal

Purchase

Other: (Explain)

If the animal(s) you are shipping is/are already insured, complete the following information:

Insurance Company: Phone:

Address: City: State: Zip Code:

Agent/Contact: Policy Number:

If the animal(s) you are shipping is/are not presently insured, we will provide insurance at the following rates:

1. Transit only (stable to stable or ranch to ranch)..................... 1.75% of Value

2. Transit plus 15 days after arrival at stable of destination ........ 2.35% of Value

3. Transit plus 30 days after arrival at stable of destination ....... 2.95% of Value

If you wish us to provide insurance for you, complete the following information: Horses 15 years or older can be insured for transit only for 2% with prior approval.

Name

Coverage
Desired

Rate

Value

Premium

Sample: Jane Doe Mare

#1

1.75%

$10,000

$175.00

If we are to provide insurance for you, please enclose a check payable to ANDREINI & COMPANY with this completed form. Animals without insurance or proof thereof will not be transported.

I/We declare the above facts confirm my knowledge and also that this insurance has not been refused elsewhere, no other insurance is in effect, or that insurance is in excess of fair market value.

I/We declare that I/we are the sole owner(s) of the animal(s) herein described and that the same is now in sound and good condition; and that there effect, or that insurance is in excess of fair market value. is not now, nor has there been any contagious disease in my/our vicinity, and that I/we know of no reason why this insurance should not be granted.

Signature of Applicant: ______________________________ Date: ___________________________

The value indicated above is based on:
Appraisal	Purchase	Other: (Explain)

If the animal(s) you are shipping is/are already insured, complete the following information:
Insurance Company: Phone:
Address: City: State: Zip Code:
Agent/Contact: Policy Number:

If the animal(s) you are shipping is/are not presently insured, we will provide insurance at the following rates:

1. Transit only (stable to stable or ranch to ranch)..................... 1.75% of Value
2. Transit plus 15 days after arrival at stable of destination ........ 2.35% of Value
3. Transit plus 30 days after arrival at stable of destination ....... 2.95% of Value

If you wish us to provide insurance for you, complete the following information: Horses 15 years or older can be insured for transit only for 2% with prior approval.
Name	Coverage Desired	Rate	Value	Premium
Sample: Jane Doe Mare	#1	1.75%	$10,000	$175.00


If we are to provide insurance for you, please enclose a check payable to ANDREINI & COMPANY with this completed form. Animals without insurance or proof thereof will not be transported. I/We declare the above facts confirm my knowledge and also that this insurance has not been refused elsewhere, no other insurance is in effect, or that insurance is in excess of fair market value. I/We declare that I/we are the sole owner(s) of the animal(s) herein described and that the same is now in sound and good condition; and that there effect, or that insurance is in excess of fair market value. is not now, nor has there been any contagious disease in my/our vicinity, and that I/we know of no reason why this insurance should not be granted.

Signature of Applicant: ______________________________			Date: ___________________________