Pet Insurance
Tel: 01992 767666

This form covers up to 2 Dogs or Cats.

If you wish to insure more than two dogs or cats on the policy, please contact us direct by telephone or send us an email

Complete the following. Your method of payment will be confirmed when we telephone you.  
email Address
Confirm email Address  
Title
First Name
Surname
House Number/Name
Street
Town
County
Post Code
Country
Tel. Number - Day
Tel. Number - Evening
   
Where Did You See Us Advertised
Existing Customer (Any Product) YES NO 
Particulars of First Animal to be Insured
Name
Breed
Sex
Dog or Cat
Date of Birth
Date of Purchase
Price Paid (inc. Currency)
   
   
Particulars of Second Animal to be Insured:  
Name
Breed
Sex
Dog or Cat
Date of Birth
Date of Purchase
Price Paid Paid (inc. Currency)
   
   
Method of Payment.
  • Have any of the above animals received veterinary treatment other than vaccinations?
YES NO
  • Has a complaint been made regarding any of the above animals?
YES NO
  • Do any of the above animals have any vicious tendencies?
YES NO
  • Are any of the above animals used in connection with any trade or business other than breeding?
YES NO
  • Have you been hospitalised for more than four days on any one occasion during the last 5 years?
YES NO

If the answer to any of the above 5 questions is "YES", please give further details in the space below (pressing 'enter' at the end of each line), or call us direct to discuss it.
Declaration: I warrant to the best of my knowledge and belief that the animal(s) described above are in good health and condition and have not suffered from any illness, disease or injury which makes the animal(s) an abnormal risk. I declare that the information I have given above is true and complete. I have not withheld any material facts (see IMPORTANT NOTES.) I agree that this proposal shall form the basis of the Contract between me and Shearwater Insurance. I am 18 years of age or over.
Shearwater Insurance Services Ltd
Registered Office: 2 Bath Place, London, EC2A 3JJ. Registered in the UK Company No: 02701633