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AMERICAN RELIABLE INSURANCE COMPANY SUBSTANTIATION OF VALUE (Risk Placement Services, Inc.)

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A8199M0915
AMERICAN RELIABLE INSURANCE COMPANY
SUBSTANTIATION OF VALUE
Applicant Name _____________________________________________ E-Mail Address _________________________________________
Mailing Address ____________________________________________ Phone _________________________________________________
City, State, Zip _____________________________________________ Policy Number __________________________________________
Horse Name
Breed
Birth Date
Color
Sex
Use
Registration Number
Sire
Dam
Purchase Date
Purchase Price
Fair Market Value
Show / Performance Record(s)
Show /
Competition
Show Rating
Class /
Division
Number of
Entries
Placement
Winnings ($)
Number of
Points
Training Record(s)
Name of Trainer
Type of Training
Cost of Training ( excluding Board, Vet and Maintenance Fees )
Per Month
Number of Months
Total Cost
$
$
Breeding Stallions
Number of Non-Owned Mares
Booked This Year
Number of Non-Owned Mares
Bred This Year
Stud Fee Charged
This Year’s Annual Breeding
Income
Number of Non-Owned Mares
Booked Last Year
Number of Non-Owned Mares
Bred Last Year
Stud Fee Charged
Last Year’s Annual Breeding
Income
Broodmare Record
Number of Live
Births Since
Owned
Number of Foals
Sold Since Owned
Average
Selling Price
of Foal
Average Selling
Price of Full
Siblings
Average Selling
Price of Half
Siblings
Is Mare
Pregnant Now?
Amount Of Stud
Fee
Foal Due Date
YES NO
$
Foal Record
Stud Fee of Sire
Average Selling Price of Full Siblings
Average Selling Price of Half Siblings
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.
Applicants Signature: Date:
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AMERICAN RELIABLE INSURANCE COMPANY SUBSTANTIATION OF VALUE (Risk Placement Services, Inc.)

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Completed 30 July 2020

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