MGS Insurance | Pet Care Insurance Application Form

Payment Term *

Insurance Plan *

Prefix

First Name *

Middle Name

Last Name *

Complete Address

Date of Birth: *

Mobile Number *

Email Address *

Name of the Pet:

Breed and Color:

Gender

Pet's Date of Birth

Pedigree Certificate No. (if any):

RFID No. (if any):

Is the Pet to be insured: (please check all that apply)

Home PetUsed for Military, Police or Security ServicesA Stunt PetRaised and used for FightingRaised and used for SportsOthers

Has the pet to be insured been given the following vaccines:

Distemper, Parvovirus, Hepatitis, Leptospirosis, Parainfluenza (5-in-1)

Rabies

Deworming

Bordetella (Kennel Cough)

Heartworm Preventive

I, owner of the pet specified, do hereby attest that my pet:

Is in good and healthy condition

Is free from sickness, illness or injury at the time of application

Has no history of any operations, sickness an d injury

Has no congenital diseases/ conditions

Undergoes regular Physical Examination and receives necessary check-ups and treatments recommended by a veterinarian to prevent illness/ injury

If you answered NO to any of the items in the Declaration of the Health Condition of the Pet, please provide further details of any past operation, illness or injury:

Declaration of No Commercial Breeding Practices

No. of Pet Dogs in the Insured's Household

No. of Pet Dogs insured with Malayan Insurance (If any)

Does the Insured engage in any commercial breeding practices or business?

Are any of these pet dogs used as for commercial breeding purposes?

Kindly attached the following documents for the Underwriter's further review:

Photo of the Pet

No file chosen

Pet Baby Book/ Veterinarian Records

No file chosen

Veterinarian's Certification on the Insured Pet's Health

No file chosen

Pedigree Certificate

No file chosen

pet care insurance application form

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