To use this form please enter your details and press Submit to email to Wallace Livestock Insurance Agency Pty Ltd

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* Name					* Postcode/Zip
Company					* Phone
* Address					Fax
* City					* Email
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Details of Horses:
Breed	Age	Sex	Sum Insured
		Gelding Mare Stallion Filly Colt
		Gelding Mare Stallion Filly Colt
		Gelding Mare Stallion Filly Colt
Purposes horse(s) used for: Please be specific - eg Show Jumping
Cover required: Mortality Transit Unborn foal Cover required: Permanent Infertility Cover required: Colic Surgery