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Policyholder Details:

Please note all these fields are required

Physical Address:

Please note all these fields are required
Address(Required)

Details of Pet:

Please note all these fields are required
Name(Required)
MM slash DD slash YYYY
Gender:(Required)
Spayed/neutered?:(Required)

INSURANCE POLICY HISTORY

Are you currently insured or have any other insurance policies in place which may cover this risk?(Required)

MEDICAL HISTORY

Please note that the non –disclosure of material information whether intended or otherwise may lead to claims being repudiated and the policy being cancelled. Where you answer YES to any question please provide full details in the space provided. Please note all these fields are required.
Has the pet been seen by any other vet besides their regular vet?(Required)
Has the pet ever been to the vet for any medical problems?(Required)
Has the pet needed medical treatment now or in the past?(Required)
Is the pet currently on any medication or prescription food?(Required)
Has the pet ever exhibited excessive licking or scratching?(Required)
Has the pet ever had any eye or ear problems?(Required)
Has this pet ever had severe vomiting or diarrhoea?(Required)
Does this pet have difficulty rising or walking?(Required)
Does this pet have any physical abnormalities?(Required)
Has this pet had any behavioural problems?(Required)
Are all vaccinations up to date? Please note that vaccinatable illnesses will not be covered if the vaccination history can not be verified.(Required)
Has this pet ever been used in competitive or commercial activities?(Required)

FOR ADOPTED PETS

(skip/leave blank if not applicable to this pet)
MM slash DD slash YYYY

Details of Pet Number 2: (Optional)

Name
MM slash DD slash YYYY
Gender:
Spayed/neutered?:

MEDICAL HISTORY

Has the pet been seen by any other vet besides their regular vet?
Has the pet ever been to the vet for any medical problems?
Has the pet needed medical treatment now or in the past?
Is the pet currently on any medication or prescription food?
Has the pet ever exhibited excessive licking or scratching?
Has the pet ever had any eye or ear problems?
Has this pet ever had severe vomiting or diarrhoea?
Does this pet have difficulty rising or walking?
Does this pet have any physical abnormalities?
Has this pet had any behavioural problems?
Are all vaccinations up to date? Please note that vaccinatable illnesses will not be covered if the vaccination history can not be verified.
Has this pet ever been used in competitive or commercial activities?

FOR ADOPTED PETS

(skip/leave blank if not applicable to this pet)
MM slash DD slash YYYY

Details of Pet Number 3: (Optional)

Name
MM slash DD slash YYYY
Gender:
Spayed/neutered?:

MEDICAL HISTORY

Has the pet been seen by any other vet besides their regular vet?
Has the pet ever been to the vet for any medical problems?
Has the pet needed medical treatment now or in the past?
Is the pet currently on any medication or prescription food?
Has the pet ever exhibited excessive licking or scratching?
Has the pet ever had any eye or ear problems?
Has this pet ever had severe vomiting or diarrhoea?
Does this pet have difficulty rising or walking?
Does this pet have any physical abnormalities?
Has this pet had any behavioural problems?
Are all vaccinations up to date? Please note that vaccinatable illnesses will not be covered if the vaccination history can not be verified.
Has this pet ever been used in competitive or commercial activities?

FOR ADOPTED PETS

(skip/leave blank if not applicable to this pet)
MM slash DD slash YYYY

Details of Pet Number 4: (Optional)

Name
MM slash DD slash YYYY
Gender:
Spayed/neutered?:

MEDICAL HISTORY

Has the pet been seen by any other vet besides their regular vet?
Has the pet ever been to the vet for any medical problems?
Has the pet needed medical treatment now or in the past?
Is the pet currently on any medication or prescription food?
Has the pet ever exhibited excessive licking or scratching?
Has the pet ever had any eye or ear problems?
Has this pet ever had severe vomiting or diarrhoea?
Does this pet have difficulty rising or walking?
Does this pet have any physical abnormalities?
Has this pet had any behavioural problems?
Has this pet ever been used in competitive or commercial activities?

FOR ADOPTED PETS

(skip/leave blank if not applicable to this pet)
MM slash DD slash YYYY

Do you have any other pets that need to be insured?

(Required)

CONTACT

Tel: (021) 551-4447
Fax: (086) 658-5804
Email: admin@catanddogsure.co.za

OFFICE

Physical Address: Unit 1, Forest Mews, Lonsdale Way, Pinelands, 7405
Postal Address: PO Box 486, Howard Place, 7450

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