B Portwood & Co Ltd Insurance Brokers

Pet Insurance Proposal Form Please use this form as a proposal form, or to raise a pet insurance query.
Your name
E-mail address
Address line 1
Address line 2
City
County
Country - must be UK
Post code
Telephone No.
Pet's name
Pedigree name
Dog or Cat?
Sum Insured (if applicable)
Age (specify weeks or years)
Policy required
Date purchased
Breed & Description of Pet (Or this information can be telephoned or faxed to B Portwood & Co Ltd)

Have you any specific demands or needs?	I have no specific demands and needs
Declaration I have completed the form to the best of my knowledge and belief. I have made a full disclosure of all material facts. I have read and understood the Important information below. I understand that there is no cover in force until confirmed by B. Portwood & Co Ltd, a satisfactory proposal form completed and accepted and payment of the premium made - either in full or an instalment plan set up acceptable to B. Portwood & Co Ltd.