Fillable AMERICAN RELIABLE INSURANCE COMPANY VETERINARIAN CERTIFICATE OF EXAMINIATION (Risk Placement Services, Inc.)

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AMERICAN RELIABLE INSURANCE COMPANY VETERINARIAN CERTIFICATE OF EXAMINIATION (Risk Placement Services, Inc.)

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A8197M0915 Page 1 of 2
AMERICAN RELIABLE INSURANCE COMPANY
VETERINARIAN CERTIFICATE OF EXAMINIATION
Applicant Name ___________________________________________ E-Mail Address _________________________________________
Mailing Address ___________________________________________ Phone _____________________________________
City, State, Zip ____________________________________________ Policy Number __________________________________________
I, (Print Name)______________________________________ do hereby certify that I am a graduate veterinarian holding a current license as such to
practice in the State of ____________ and that I have this day examined:
Horse Name/Tattoo/Reg #
Breed
Age
Color
Sex
Use
Owned by (Name / Address):
1
Yes No
14
Has Horse been castrated?
Yes No
2
Yes No
15
If male, are both testicles evident?
Yes No
3
Yes No
16
Any evidence of bone or joint disease?
Yes No
4
Yes No
17
Hoof tester results negative?
Yes No
5
Yes No
18
Is horse properly shod?
Yes No
6
Yes No
19
Gestation, lactation or parturition history?
Yes No
7
Yes No
20
Any evidence of infection or disease?
Yes No
8
club foot?
Yes No
21
Is stabling adequate?
Yes No
9
Yes No
22
Is Horse pregnant? If yes, Expected birth date:
Yes No
10
Yes No
23
HYPP Tested? : N/N N/H H/H
Yes No
11
osteochrondrosis on any X-rays taken?
Yes No
24
Aware of any condition, past or present that could
require surgical or medical attention in the next 12
months?
Yes No
12
Yes No
25
Any history of unsoundness, injury or disease?
Yes No
13
Yes No
26
How often wormed? ______________________
Date Last worming?_______________________
27
Aware if horse received any performance enhancing procedures, intramuscular and /or joint injections, any medications, or any
preventive treatments in the last 12 months?
Yes No
28
Palpations normal? Back, Stifles, Knees, Hocks, Fetlocks, Tendons / Ligaments
Yes No
29
Have you or any other licensed equine veterinarian attended horse for any ailment, injury, lameness, or medical problem in the last
12 months?
Yes No
31
Does the horse appear relaxed or free of pain in all gaits / movements observed?
Yes No
32
Have you observed the horse in gaits / movements for its breed and use?
Yes No
33
Are you the regular veterinarian for this horse or applicant? If so, for how long? __________________
Yes No
Comments to questions requiring further detail: (Include General evaluation for named horse, professional opinion on soundness)
EXCEPT AS NOTED ABOVE, I HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THE HORSE IS, EXCEPT AS NOTED, SOUND.
Veterinarian’s Signature Address: Date: Phone#
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A8197M0915 Page 2 of 2
Back Of Form
LOSS OF USE EVALUATION
If Loss of Use Coverage is being requested, please complete the following:
• X-rays: Current within 30 days
o Front Feet – Lateromedial, dorsal ventral, navicular skyline
o Front Fetlocks – A/P Views
o Hind Fetlocks – A/P views
o Hocks – Lateral projection, craniocaudal projection, both oblique
o Stifles – Lateromedial views
Please list radiographic findings, especially which may affect horse’s long and short term intended use.
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Completed 30 July 2020

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