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AMERICAN RELIABLE INSURANCE COMPANY E QUINE MORTALITY & (Risk Placement Services, Inc.)

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A8049A0518 Page 1 of 3
AMERICAN RELIABLE INSURANCE COMPANY
E
QUINE MORTALITY & MEDICAL APPLICATION
AP
PLICANT INFORMATION
Preferred Effective Date for Policy Inception: ___________________ Email Address ___________________________________________
Named Insured (DBA) _______________________________________ Phone # ________________________________________________
Mailing Address ____________________________________________ Web Address (if Any) _____________________________________
City ________________________ State _______ Zip _____________
Name / Address of Horse Boarding Location(s) ______________________________________________________________________________
COVERAGE OPTION
S
-
HORSE # 1
(
√)
COVERAGE OPTION
S
-
HORSE # 2
(
√)
Equine Mortality (Includes Free Colic Surgery)
Equine Mortality (Includes Free Colic Surgery)
Equine Mortality
–
Specified Perils Only
Equine Mortality
–
Specified Perils Only
Equine Major Medical / Surgical Limits
$ 7,500 /$425 Ded.
$10,000 /$500 Ded.
$15,000 /$600 Ded.
Equine Major Medical / Surgical Limits
$ 7,500 /$425 Ded.
$10,000 /$500 Ded.
$15,000 /$600 Ded.
Equine Surgical Only $5,000 / $375 Ded.
Equine Surgical Only
$5,000 / $375 Ded.
Equine Colic Coverage $3,000 / $375 Ded.
Equine Colic Coverage $3,000 / $375 Ded.
Equine Accident & Illness $5,000 / $375 Ded.
Equine Accident & Illness $5,000 / $375 Ded.
A, S & D Infertility (For Stallions)
A, S &
D Infertility (For Stallions)
Equine Loss of Use
*
Equine Loss of Use
*
Worldwide Coverage
Worldwide Coverage
*Subject to age, value and use guidelines and supplemental underwriting information.
HORSES OWNED / LEASED BY APPLICANT
Horse Name Sex DOB Requested
Mortality Limit
Breed Use Date
Purchased
Purchase Price or
Trade Exchange Value
Details
1
2
1
Seller
Name/Address
:
Horse’s
Sire:
Horse’s
Dam:
2
Seller Name/Address:
Horse’s
Sire:
Horse’s
Dam:
Has any insurance carrier ever canceled, non-renewed or refused to insure any horse(s) in which you have
or had an insurable interest? (Not applicable in Missouri)
No Yes
Have you ever had a claim involving injury, death, or loss of an insured horse with any insurance
carrier?
No
Yes
If Yes:
Date of Loss
Coverage Type
Description of Claim
Amount Paid
Insurance Carrier
A8049A0518 Page 2 of 3
ADDITIONAL
QUESTIONS
Horse #1
Horse #2
1
Was a pre-purchase examination completed? (Note: Pre-purchase examination is not the
Veterinarian’s Certificate of Examination. Company may reject results.)
No Yes No Yes
2
Is the horse healthy and capable of performing its stated use?
No Yes No Yes
3
Has the horse received any type of medication or treatment other than well / routine horse care?
No Yes No Yes
4
Has the horse ever received medical or surgical treatment, including joint injections, or nerve blocks
for lameness?
No Yes No Yes
5
Has the horse ever had any colic, colic surgery, gastric ulcer, impaction, or intestinal disorder?
No Yes No Yes
6
To the best of your knowledge, has your horse ever been observed or diagnosed with, or treated for
eye disease, moon blindness or head shyness?
No Yes No Yes
7
To the best of your knowledge, has your horse ever been observed or diagnosed with, or treated for
conformation problems or defects, injury, or evidence of lameness?
No Yes No Yes
8
Does the horse have a gait deficit or neurologic disorder?
No Yes No Yes
9
Does the horse have any past Laminitis, founder, Navicular Syndrome, abscess, P3 rotation, or other
hoof problems or irregularities?
No Yes No Yes
10
Does the horse have any Osteoarthritis, degenerative joint disease or OCD?
No Yes No Yes
11
Has the horse undergone diagnostic ultrasound, bone scan or X-rays within last 36 months?
No Yes No Yes
12
Will the horse be observed and cared for daily?
No Yes No Yes
13
What percentage of time per day is the horse in pasture (not in stable)?
% %
14
How many miles is the horse to the closest licensed equine veterinarian?
15
Is the horse leased? If yes, attach copy of lease agreement. If no written agreement, explain terms in
“comments” section.
No Yes No Yes
16
Is applicant the sole owner of the horse? If no, provide other owner’s name(s), address(es), and %
interest.
No Yes No Yes
17
Is there any other insurance on the horse? If yes, provide details in “comments” section.
No Yes No Yes
18 Has the horse ever shown any HYPP signs or symptoms? No Yes No Yes
19
Has the horse ever been HYPP tested?
Test Results: N/N 1 2 N/H 1 2 H/H 1 2
No Yes No Yes
20 What is the horses primary licensed equine veterinarian’s name, address & phone #:
21 Loss Payee(s) Name / Address:
22
Do you understand that the insurance policy you are applying requires you to give the company
immediate notice of any covered animal’s death, injury, sickness or disease, along with a description
of the condition and name of the attending veterinarian? Do you also understand that failure to
provide immediate notice may result in the denial of a claim?
No Yes No Yes
A8049A0518 Page 3 of 3
Comments to Questions Requiring Additional Explanation:
Copy of the Notice of Information Practices (Privacy) has been given to the applica
nt. (Not required in all states;
contact your agent
or broker for your state's requirements.)
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN
YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED
INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR
AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY
INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON
REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
In AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or
benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison. *Applies in MD Only.
In CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
In FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
In KS: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A
fraudulent insurance act means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or
prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer or insurance agent or broker, any written, electronic,
electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for insurance, or
the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially
false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.
In KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five
thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.
In ME, TN, VA and WA:
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
In NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
In OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false
statement as to any material fact may be violating state law.
In PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or
causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or
loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not
more than ten thousand dollars ($10,000) or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances
[be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
I, the undersigned, hereby certify that to the best of my knowledge and belief the information provided is true and complete and I have not
withheld any material information. It is agreed that this form shall be the basis of the contract and / or policy should a contract and / or
policy be issued and if anything be falsely stated or information withheld to influence the company’s decision, the insurance contract and
/ or policy will be null and void.
Applicant Signature: Date:
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AMERICAN RELIABLE INSURANCE COMPANY E QUINE MORTALITY & (Risk Placement Services, Inc.)

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Completed 30 July 2020

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