Petsecure Insurance Enrollment

Please complete this form only if you are interested in enrolling in the Petsecure 6-week free insurance trial.

Note: Submitting this form does not guarantee registration.

Our volunteers will use the information from your adoption contract to complete the registration process within the next week.

仅在您有意注册 Petsecure 提供的 6 周免费保险试用时填写此表格。

请注意：填写此表格并不代表注册成功。

我们的志愿者将在接下来的一周内，根据您的领养合同中的信息完成保险试用的注册流程。

Animal Name // 动物名字 *

*This field make take a while to load. // 此栏可能需要一些时间加载。

Adopter Name (same as it appears on your adoption contract) // 领养人姓名（需与您领养合同上的姓名一致） *

Animal ID // 动物编号 *

*you may find on your adoption contract (red box below) // 您可以在领养合同中找到（如下图红框所示）

Email // 邮箱 *

*we will send a confirmation to this email // 确认信息将发送至此邮箱

Pick-up Date of the Animal // 动物接领日期 *

Acknowledgement // 确认声明 *

I acknowledge the pick up date of the animal I entered above is truthful. // 本人确认上述所填写的动物接领日期属实。

Signature // 签字 *

Draw your signature above