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THE HARTFORD
LIVESTOCK DEPARTMENT
www.hartfordlivestock.com
(Minimum Earned Policy Premium $250.00)
Producer’s Name
Applicant’s Name
Agency Code
87 -
Mail Address
Mail Address
City, ST Zip
City, ST Zip
Phone
Phone
Fax
Fax
E-Mail Address
E-mail Address
Policy Term Desired (maximum term 12 months):
Individual Partnership Corporation Joint Venture Limited Liability Corp. Other
Proposed Effective Date: _____________ New Policy
(Coverage begins on the date of acceptance by the Company) Endorsement (Policy Number)
Installment Payment Plans? Yes No
(Available on Premiums over $500)
A. Animal Name
Date of Birth
Date of Purchase Purchase Price (or stud fee if raised) Requested Limit of Insurance
Identification (Sire/Dam, Registration#, Tattoo#, Microchip#, or Pictures if unregistered) Sex (Stallion, Mare, Colt, Filly, Gelding) Breed Use
Primary Stable Location:
B. Animal Name
Date of Birth
Date of Purchase Purchase Price (or stud fee if raised) Requested Limit of Insurance
Identification (Sire/Dam, Registration#, Tattoo#, Microchip#, or Pictures if unregistered) Sex (Stallion, Mare, Colt, Filly, Gelding) Breed Use
Primary Stable Location:
All Limits of Insurance are subject to company approval.
For a Requested Limit of Insurance that does not equal the Purchase Price, complete and attach a Substantiation of Value.
Type of Coverage Requested:
A B A B A B
Mortality - Full Major Medical $7,500 Loss of Use
Mortality - Limited Major Medical $10,000 Loss of Use-Limited
Renewal Protection Major Medical $15,000 Surgical $5,000 Limit
Major Medical $5,000, Basic Major Medical $10,000 high deductible Aggregate Deductible
Major Medical $7,500, Basic Accident, Sickness and Disease Other _________________
Horse A
Y N
Horse B
Y N
1. Was a pre-purchase exam completed? If Yes, a copy of the examination results may be requested by the Company.
2.
Has the horse been examined or treated by a veterinarian for any accident, injury, sickness, disease, lameness, or other
than routine care within the last year?
3. Is the horse currently free of lameness and healthy without the use of drugs?
4. Has the horse undergone diagnostic ultrasound, bone scan, or x-rays within the last 36 months?
5.
Does the horse have any past conformational problems or defects, illness or disease, lameness, or injury or physical
disability including, but not limited to: laminitis/founder, OCD, neurological disorders (e.g. EPM) navicular disease, and/or
degenerative joint disease?
6. Has the horse been nerved or received any treatment for lameness?
7.
Has the horse received any joint injections, any type of medication long or short term, or any preventative treatments in the
last 36 months?
8. Has the horse had any colic, colic surgery, impaction, or intestinal disorder within the last 36 months?
9.
Is the horse due to foal any time during the requested Policy Period?
If Yes, please give:
Estimated Foaling Date:
; Number of Previous Foals: ; Stud fee:
10. Has the horse ever experienced birthing difficulties? (Mares only)
11. Does the horse have an ancestor known to carry HYPP? If No, please move on to question 12.
a. Has the horse been HYPP tested? If Yes, please check the test results.
N/N A B N/H A B H/H A B
b. Please check the HYPP test results of the horse’s Sire and Dam.
Sire: N/N A B N/H A B H/H A B Unknown A B
Dam: N/N A B N/H A B H/H A B Unknown A B
c. Has the horse ever shown any HYPP signs or symptoms?
Page 1 of 3 © The Hartford, 2011 LS 16 01 12 11
Jan 4, 2012
ANIMAL MORTALITY APPLICATION
for HORSES
12. Will the horses be observed and cared for daily? Yes No If No, explain:
13. Who was each horse acquired from?
14. Are you the sole owner of the horses? Yes No If No, provide other owner’s % of interest, name and address:
15. Loss Payee(s):
(Name and Address)
16. If the Purchase Price was not paid entirely in cash, please describe the transaction in detail.
17. Are the horses leased to others? Yes No If Yes, please attach a copy of the lease(s).
18. Is there any other insurance on the horses? Yes No If Yes, provide the carrier name:
Expiration date: Amount of coverage:
19. Has any insurance carrier ever canceled, non-renewed or refused to insure any horse in which you have or had an insurable
interest? Yes No If Yes, provide details: (Not applicable in MO)
20. Have you lost any horse in the last 5 years (whether or not insured) or have any medical/surgical or colic claims been filed on the above listed
horse?
Yes No
If Yes, give date, cause, value and explain:
21. Name, address, and telephone number of the horse’s primary licensed Veterinarian:
22. Do you understand that the insurance policy you are applying for 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 the name of the attending veterinarian? Do you also understand
that failure to give this immediate notice may result in the denial of a claim?
Yes No
Please provide details for any “Yes” answers to questions 2,4,5,6,7,8,10 and 11c. and any “No” answers to questions 3 and 22.
Note: A Veterinarian Certificate of Exam is
required if:
1. Horse is under 6 months of age
2. Horse is over 16 years of age
3. Horse is valued over $50,000
4. You have not known the horse over 30 days
(A pre-purchase exam no older than 30 days can be submitted in place of the vet exam)
Page 2 of 3 © The Hartford, 2011 LS 16 01 12 11
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT.
(Not applicable in all states, consult 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 INCONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND
PRIVILEGED INFORMATION COLLECTED BY USOR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEWYOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST
CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS ANDOUR PRACTICES REGARDING SUCH
INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMITA REQUEST
TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER
PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING
ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND
SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (Not applicable in CO, DC, FL,
HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING
INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDINGTHE INSURER OR ANY OTHER
PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY
INSURANCE BENEFITS, IFFALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE
APPLICANT.
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR ANAPPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR
MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
IN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE ORBELIEF THAT IT WILL BE PRESENTED TO OR BY AN
INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART
OF,OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE
POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR ACLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH
PERSON KNOWS TOCONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL
THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATIONCONCERNING ANY FACT
MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH
INTENT TO DEFRAUD ANY INSURANCE COMPANY ORANOTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FORTHE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BEA CRIME AND MAY
SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OFDEFRAUDING THE COMPANY.
PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT
REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION.
HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF
HIS/HERKNOWLEDGE.
APPLICANTS SIGNATURE DATE (Must be no more than 30 days prior to policy effective date)
PRODUCERS SIGNATURE PRODUCERS NAME(Please Print) STATE PRODUCER LICENSE NO.
(Required in Florida)
Page 3 of 3 © The Hartford, 2011 LS 16 01 12 11
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Producer’s Name
Applicant’s Name
Agency Code
Mail Address
Mail Address
City, ST Zip
City, ST Zip
Phone
Phone
Fax
Fax
E-Mail Address
E-mail Address
Horse Name: Date of Birth: Sex: Use:
For Quarter Horses, Appaloosas, or Paints that have an ancestor known to carry HYPP, please indicate the horse’s HYPP status (check one.) N/N N/H H/H N/A
Has the horse experienced any HYPP signs or symptoms?. Yes No If Yes, please explain:
Pulse and Respiration normal at rest and after work? ........... Yes No
Heart auscultation normal at rest and after work? .................
Yes No
Respiration auscultation normal at rest and after work? ........
Yes No
Temperature normal?.............................................................
Yes No
Eyes clinically normal?...........................................................
Yes No
Palpations normal?
Back ...............................................................................
Yes No
Stifles .............................................................................
Yes No
Knees.............................................................................
Yes No
Hocks .............................................................................
Yes No
Fetlocks..........................................................................
Yes No
Tendons and Ligaments.................................................
Yes No
(Please note any swelling, heat, stiffness and/or pain for any answer “No”.)
Hoof tester results negative? ................................................. Yes No
Properly shod? .......................................................................
Yes No
Is the stabling and turn out safe and adequate? ....................
Yes No
If any are answered no, please explain on a separate page
Are you the usual veterinarian for the applicant?................... Yes No
If no, have you treated/examined this horse previously? Explain:
Has the horse ever had colic surgery?...................................
Yes No
Subject to or any previous history of colic?............................
Yes No
History or evidence of a bleeder?...........................................
Yes No
History or evidence of nerving?..............................................
Yes No
Any evidence or history of laminitis, club foot, or P3 rotation? ....
Yes No
Any evidence of infection or disease?....................................
Yes No
Contagious diseases on premises or locally? ........................
Yes No
Is there evidence of objectionable habits? Vices? .................
Yes No
Any history of uncharacteristic behavior in the last 24 months?.....
Yes No
Any major conformation faults, which may affect the
horse for its intended use, short or long term?..................
Yes No
Any evidence of lameness jogging straight or
on circles in both directions? .............................................
Yes No
Any evidence of bone or joint disease?..................................
Yes No
Is the horse subject to chronic metritis and/or mastitis?.........
Yes No
Is the horse pregnant? ...........................................................
Yes No
If Yes, give expected date of birth: _______________
If the horse is a breeding horse, to your knowledge is there
any history of gestation, lactation or parturition problems? .
Yes No
If any are answered yes, please explain on a separate page.
Are you aware if the horse has received any performance enhancing procedures, including intramuscular and/or joint injections, any type of
medication long or short term, or any preventative treatments in the last 12 months?....................................................................................
Yes No
Have you or any other veterinarians attended the horse for any ailment, injury, lameness, or medical problem in the last 12 months?................
Yes No
Has the horse ever undergone surgery?..................................................................................................................................................................
Yes No
Are you aware of any condition, past or present that could require surgical or medical attention in the next 12 months?......................................
Yes No
Are you aware of any history of unsoundness, injury or disease on this horse? .....................................................................................................
Yes No
Other findings or remarks? ____________________________________________________________________________________
Provide details of any degenerative changes, bone spurs, chips or osteochondrosis seen on any radiographs taken.
If any are answered yes, please explain on a separate page.
If Loss of Use Coverage is being requested, please complete the following:
X-rays: Must be current within 30 days. Please list below all radiographic findings, especially those that may affect the horse’s long term and short-term
intended use. If possible, use any previous X-rays for comparisons, i.e. navicular. All views listed below are required for Full Loss of Use coverage. If
additional views were taken, please describe results. Use a separate page if necessary. Note NSF and WNL are not acceptable descriptions for findings.
Front Feet - Lateromedial, dorsal ventral, navicular skyline:
Front Fetlocks - A/P views:
Hind Fetlocks – A/P views:
Hocks – Lateral projection, craniocaudal projection, both oblique:
Stifles – Lateromedial views:
Give your general evaluation for the above named horse, and your professional opinion on soundness, both short and long term, for its intended use.
Veterinarian’s Signature Date Telephone Number
Veterinarian’s Address:
LS 16 02 12 11
Mar 15, 2012
VETERINARIAN’S STATEMENT OF EXAMINATION
For Horses
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