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The Hoffberger Insurance Group 5700 Smith Avenue Baltimore, Maryland 21209-3610 Office: 410-542-3300 Fax: 410-542-3399 Nights/Holidays: 410-484-0656 653-3046 |
Directions for using this form: Print this form; Fill it in completely; Sign it; and mail or FAX to: The Hoffberger Insurance Group, 5700 Smith Ave., Baltimore Maryland 21209-3610; FAX 410-542-3399 |
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Instructions to Veterinarian: It is required in every case that the animal should be examined outside of the stall and that it should be made about to demonstrate soundness of limbs and freedom of action. Animals having vicious habits; that are chronic colickers; that are tuberculous; that are not acclimated; that have ever been nerved; are not insurable. Careful observation and inquiry should be made as to housing conditions and presence of contagious disease. |
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I, _________________________________________ do hereby certify that I am a graduate Veterinary Surgeon, holding a current license to practice as such by the ________________ ___________________________and that I have this day examined the: |
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| Breed: | ________________________________ | Color: | ___________________________________ |
| Kind And Sex: | ____________________________________________ | Age: | _______________ |
| Named: | __________________________________________________________________ | ||
| Sire: | __________________________________ | Dam: | __________________________________ |
Markings or Tattoo No: |
____________________________________________________________ |
| Property of: | ____________________________________________________________ |
| of: | ____________________________________________________________ |
| If mare, is animal in foal?: __________ Is pulse & respiration normal? _________________ |
| Are both eyes of animal perfect?: _____________________________________________________ |
| Any lameness or faulty conformation?: ____________________________________ __________________________________________________________________________________ __________________________________________________________________________________ |
| Is the animal subject to attacks of colic?: ______________________________________ | |||||
| Has Neurotomy been performed on this animal? (Nerved): __________________ | |||||
| Has any other operation been performed on this animal?: _______________________ __________________________________________________________________________________ __________________________________________________________________________________ | |||||
| If so, has the animal fully recovered?: _____________________________________________ | |||||
| Is there any likelihood of future danger to life or limb as a result of such operation?: __________________________________________________________________________________ __________________________________________________________________________________ | |||||
| REMARKS: ______________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ | |||||
| I found the housing to be __________________, and I discovered ____________________ | |||||
| (if none, so state) contagious disease present; and except as noted above, I hereby certify that the animal is in sound and healthy condition. | |||||
| Signed: ______________________________________ Date Of Examination: ________________ | |||||
| Address: ______________________________________________________________________ |
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The Hoffberger Insurance Group
5700 Smith Ave.
Baltimore Maryland 21209
ph:(410)542-3300
Outside MD: 1-800-547-5501
FAX: (410)542-3399