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Dutta Incident Report

Owner Name

Contact Phone Number (Include Country Code)

Contact Email

Confirm Email

Temporary Mailing Address

Permanent Mailing Address

Passport #

Horse Name

Chip #

Horse Name In Barn

Breed

Horse Sex

Age

Color

Shipping Company

Depart From What Airport

Arriving At What Airport

Incident Information

Incident Type

Name Of Incident Filer

Date Of Incident

Time Of Incident

AM or PM

Describe The Nature Of The Incident

Location Of Incident

Where Did The Incident Take Place During The Trip?

Name Of Vet That Treated The Animal

Vet Phone Number

Vet Email

Has The Owner Purchased Commercial Insurance For The Affected Horse?

Yes No

Did The Horse Die?

Yes No

Was The Horse Euthanized?

Yes No

If The Incident Is Approved, Who Should The Benefit Check Be Made Payable To?

If The Incident Is Approved, Where Should The Benefit Check Be Mailed?

Street Address

City

State

Zip

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Signature (your name with the /s/ before it)

Date

By clicking "Send" Under Penalty Of Perjury, You Swear And Affirm That The Foregoing Facts Are True And Correct. Should Any Of The Information That You Submit Be False, You Understand Any Request For Reimbursement May Be Denied.

By Clicking Send, You Understand And Agree That All Incident Reports Have To Be Submitted Within Three (3) Days Of The Incident Occurring.

(*Exceptions may be made by Transporter in extreme, extenuating circumstances, like an act of God or acute, personal hardship that interfere with the ability to submit an incident form.)

Report An Incident

Dutta Incident Report

Owner Name

Contact Phone Number (Include Country Code)

Contact Email

Confirm Email

Temporary Mailing Address

Permanent Mailing Address

Passport #

Horse Name

Chip #

Horse Name In Barn

Breed

Horse Sex

Age

Color

Shipping Company

Depart From What Airport

Arriving At What Airport

Incident Information

Incident Type

Name Of Incident Filer

Date Of Incident

Time Of Incident

AM or PM

Describe The Nature Of The Incident

Location Of Incident

Where Did The Incident Take Place During The Trip?

Name Of Vet That Treated The Animal

Vet Phone Number

Vet Email

If The Incident Is Approved, Who Should The Benefit Check Be Made Payable To?

If The Incident Is Approved, Where Should The Benefit Check Be Mailed?

Street Address

Street Address

City

State

Zip

Signature (your name with the /s/ before it)

Date

Incident Successfully Submitted

Have Questions?