Cattle & Livestock Insurance

Name of the Proposer

Applicants DOB

Village

Taluka

District

State

Pincode/Post Code

Residential Address

Landmark Address

Farm Address (If Different)

Occupation

Animals Proposed for Insurance

Hypothecation

Is cover required for Permanent Disability?

#	Type	Gender	Age	Breed	Colour	Tag No.	Value (₹)	Horns	Tail	Ear	Actions
1

You can add multiple animals

Health & Veterinary Services

Purpose

Where are animals stabled?

Milk Yield(Liters/day)

Pregnancy Status

Number of Lactations

Are the animals healthy?

If No, give reason

Veterinary Services

Losses (Last 3 Years)

Have you lost any animals during the last three years? If so brief particulars.

#	Year	Cause of Loss	Number Lost	Actions
1

Previous Cattle Insurance & Claims (Last 3 Years)

#	Year	Policy No.	Name of Insurer	Claim Amount	Status	Actions
1

Other Details

How many other animals do you own and what type?

Are they insured and if so with which insurer?

If not, why are they not proposed for insurance now?

Were they insured previously and if so where?

Previously insured (Company / Underwriter)

Has any Company or Underwriter:

(a) Declined insurance of any of your animals

(b) Declined to renew the insurance

For what period is insurance required? (months) & from

Mobile Number

Account Holder Name

Bank Name

Account Number

Confirm Account Number

IFSC Code

Branch Name

UPI ID

SFDA / MFAL project details (if applicable)

Any other information material to the risk

I / we hereby propose to insure the above-mentioned animals owned by me / us with Bajaj Allianz General Insurance Co. Ltd. subject to the terms & conditions and exclusions of the Company’s Policy...

Signature of proposer

Type name here

Attached Document

Attach Veterinary Certificate(s)

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