Livestock Insurance Claim Form - Birdview Microinsurance

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Birdview Insurance

Livestock Claim Form

The issue of this form is not to be taken as an admission of liability.

PARTICULARS OF INSURED

Name of the Insured

P.O. Box

Code

Town

Mobile No

Location of the farm

PARTICULARS OF ANIMAL(S) CLAIMED FOR

Attach the ear tag and the carcass photograph

Ear Tag Number / Name	Age (yrs)	Breed	Value prior to illness (Kshs)	Action

Upload Ear Tag Photo *

JPEG or PNG (Max 5MB)

Upload Carcass Photo *

JPEG or PNG (Max 5MB)

Illness & Treatment Details

When was the animal first seen ill?

Did you notify a vet doctor of the animal illness? *

YesNo

Veterinary Surgeon Details

Name of Veterinary Surgeon

Address

Mobile No

I/We the above named do hereby to the best of my/our knowledge and belief warrant the truth of the foregoing statements in every respect and affirm that proper care and treatment was given to the animal(s). I/We agree that if I/ We have made or in my further declaration the Company may require in respect of the said accident, incident or disease shall make any false statement or any suppression or concealment, the Policy shall be void and all rights to recover thereunder in respect of the past or future accidents, incidents or disease shall be forfeited.

Signature of Insured

Date