Animal mortality 20180117
Se
ction 3 – Horse information
| Horses currently in transit are not insurable. Rates vary by state and coverage restrictions may apply.
1. Horse name: Color:
For unnamed foal, sire’s name:______________________________ Dam’s name: _____________________________
Registration number (photos required for unregistered horses):
2. Date of ownership: Date of birth:
3. Purchase price or stud fee paid: $ Amount of insurance**: $
**Note: If amount of insurance does not equal purchase price/stud fee, attach full details including substantiation of value.
4. a. Breed: _______________ Use: __________________________ Sex: ______; If mare, in foal? Yes | Due date:
NOTE: Horses who are due to foal within 30 days or who have foaled in the past 30 days are ineligible.
b. If showing and/or competing, list classes/divisions:
5. a. Method of payment: cash check
trade other: ______________________________________________
b. If trade, provide details:
6. a. Are you the sole owner? Yes No
b. If no, other owner’s name and address:_______________________________________________________________
7. Is horse being leased to or from another party? (If yes, complete leased JOV form.) Yes No
8. a. Do you have care, custody and control of this animal? Yes No
b. If no, provide name and address of person who does:
Declaration of Health: At inception of the policy, all animals must be sound, healthy and have no known injury, illness, lameness
or disease. Pre-existing conditions are not covered, unless otherwise noted and agreed to by the Company.
9. Is the horse on an inoculation and deworming program approved by a veterinarian? Yes No
10. Does the pedigree have HYPP linkage? (Note: H/H horses are not insurable.) Yes No
11. Does your horse have, or has it had, any of the following health conditions? Yes No
• History of injury, illness, lameness or disease
• Colic or any other gastro-intestinal related disease
• Surgery (other than castration), been fired, blistered, nerved,
treated or examined for lameness
• Conformation that affects the horse’s ability to be used for the
purpose described on this application
• Vet examination for anything other than routine care
• Receives medication
12. If yes to question #10 and/or #11, provide details [date(s), test results, diagnosis, treatment, recovery]. A current vet exam may be required.
Additional details or comments about this horse:
Section 4 – Optional Coverages | Additional premiums apply. Optional coverage premiums are fully earned and not eligible for refund if policy is canceled.
Emergency colic surgery - $2,500 limit included | Increase to $5,000 limit
Surgical only - $5,000 limit [$50 deductible] | $10,000 limit [$50 deductible]
Medical surgical (20% co-payment applies) – select limit: $5,000 limit $10,000 limit $15,000 limit
select deductible: $375 deductible $500 deductible $1,000 deductible
Private horse liability - $300,000 limit | $1,000,000 limit
Note: If selected, this is applied to all insured animals. Not applicable for commercial equine operations.
Limited permanent disability (available to performance horses greater than $10,000 only [not all uses]; a vet exam will be required.)
Stallion infertility due to accident, sickness or disease (a vet exam will be required)
International transit
Fair Credit Report Act Notice: Personal information about you, including information from a credit or other
investigative report, may be collected from
persons other than you in connection with this application for insurance and
subsequent amendments and renewals. 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.
Credit scoring
information may be used to help determine either your eligibility for insurance or the premium you will be charged. We
may use a third party
in connection with the development of your score. You may have the right to review your personal
information in our files and request correction of any
inaccuracies. You may also have the right to request in writing that
we consider extraordinary life circumstances in connection with the development of your
credit score. These rights may
be limited in some states. Please contact your agent or broker to learn how these rights may apply in your state or for
instructions on how to submit a request to us for a more detailed description of your rights and our practices regarding
personal information.
Fraud Warning: Any person who knowingly and with intent to defraud any Insurance Company or another 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 the person to criminal and civil penalties. (Not applicable in AL, AR, CO, DC, FL, KS, KY,
LA, MD, ME, MN, NJ,
NM, NY, OH, OK, OR, PA, RI, TN, VA, VT, WA, and WV) (Insurance benefits may also be denied in LA, ME, TN, and VA.)
Authorization - I hereby certify that to the best of my knowledge and belief the information provided is true and correct
and that no information which
would materially affect this insurance has been withheld.
NOTE: Before electronically signing this document, verify
your information is correct. Electronically signing will disable further editing of your application.
Applicant’s signature & date: Agent’s signature & date:
Authorized submitter: _________________________________Agent’s resident license number:
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