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Owner Details Insurance Coverage Classic Basic Pet Details Dog Cat Male Female Known Not known

Has the pet to be insured in the following:

Distemper, Parvovirus, Hepatitis, Leptospirosis, Parainfluenza (5-in-1, Dogs Only) Yes No

Rabies Yes No

Deworming Yes No

Bordotella Yes No

Heatworm Preventive Yes No

FVRCP Vaccine (Cats Only) Yes No

Feline Leukemia Virus (FeLV) Vaccine (Cats Only) Yes No

Declaration of Health Condition of the Pet

Is in good healthy condition Yes No

Is free from sickness, illness or injury at the time of application Yes No

Has no history of any operations, sickness or injury Yes No

Has no congenital diseases/conditions Yes No

Undergoes regular Physical Examination and receives necessary check-ups and treatments recommended by a veterinarian to prevent illness/injury Yes No

Does the Insured engage in any commercial breeding practices or business? Yes No

Are any of these pet dogs/cats used for commercial breeding purposes? Yes No

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