VETERINARIAN’S STATEMENT OF EXAMINATION FOR MORTALITY INSURANCE
Horses examined for insurance should be moved about outside the stall and observed for any abnormalities in movement or
conformation. Careful observation and inquiry should be made as to housing conditions and the presence of contagious
disease.
I,
, do hereby certify that I am a graduate Veterinarian holding a current license to
practice in the State of and that I have this day examined the following animal at rest and in motion:
Name
(USE BACK OF PAGE FOR MORE THAN ONE HORSE) Age Color Sex Breed
Sire Dam
Markings/Tattoo
Owned by
Name Address
YES NO YES NO
Pulse and respiration normal? History or evidence of nerving?
Temperature normal? Has horse been castrated?
Eyes clinically normal? Any report or clinical evidence of other surgery?
Heart auscultated? If mare, is she reported in foal?
History or evidence of bleeding? If male, are both testicles evident?
Has horse ever had colic surgery? Any history or evidence of laminitis?
If surgery has been performed, describe type of surgery and give date of surgery:
If surgery has been performed, has horse clinically recovered?
Is there any likelihood of future danger to life or limb as a result of such surgery?
Any clinical evidence of lameness, faulty conformation or other abnormal conditions?
Is the stabling adequate?
In your opinion or to your knowledge, are there any additional medical facts that should be brought to the attention of the
company? Give details including date(s)
Is there evidence of vices or objectionable habits?
If male, are genitalia of normal size and consistency for a horse this age? Yes No
Has official E.I.A. test been run? Date Lab # Result
Remarks
For Foals under 30 days of age: IgG
WBC
Is foal presently on any medications, give details:
This certificate has been completed by the examining veterinarian to the best of his or her ability as a licensed
veterinarian.
Date and Time of Examination Veterinarian’s Signature Telephone Number
Veterinarian’s Address
