2. Animal Description
4. What type of animal(s) is it?*
   -- Select One --BirdCatDogReptileRodent
5. What size is the animal?
   -- Select One --LargeMediumSmall
7. What color is the animal?
9. Animal Condition
11. Does the animal have shelter?
    -- Select One --YesNo
12. Does the animal have water?
    -- Select One --YesNo
14. What are the sanitary conditions?
    -- Select One --Clean sanitaryDirty unsanitaryHazardous to the animal
15. Where is the animal injured?
    -- Select One --BodyHeadLegsNeck
17. Does the animal have a skin condition?

    Check all that apply.

    1. Hair loss
    2. Sores
    3. Other
    4. Unknown
18. What is the physical condition of the animal?

    Check all that apply.

    1. Backbone
    2. Beaten
    3. Cut
    4. Hips
    5. Injured

    1. Ribs
    2. Shot
    3. Stabbed
    4. Thin
    5. Other
20. Please list any additional information or comments regarding your claim.
22. If a resident/vehicle/person is involved with the threat or injury of the animal please list all known information.
24. Suspect First Name
25. Suspect Last Name
27. Suspect Address
29. City
30. State
31. Zip Code
33. Suspect Phone Number
35. Suspect Vehicle Type
36. Suspect Vehicle Color
37. Suspect Vehicle Make & Model
39. Please provide your name and contact phone number. We may need to contact you for more information about your claim.
41. First Name*
42. Last Name*
44. Address
46. City
47. State
48. Zip Code
50. Phone Number*
51. Email Address*
53. Do you wish to remain anonymous?
    -- Select One --YesNo
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field