Color/Markings of Horse #1: *Required

Gender of Horse #1:  Male    Female  *Required

Name and Breed of Horse #2:

Date of Birth of Horse #2:

Color/Markings of Horse #2:

Gender of Horse #2:  Male    Female

Name and Breed of Horse #3:

Date of Birth of Horse #3:

Color/Markings of Horse #3:

Gender of Horse #3:  Male    Female

Name and Breed of Horse #4:

Date of Birth of Horse #4:

Color/Markings of Horse #4:

Gender of Horse #4:  Male    Female

Coverage Desired (please check):
Full Mortality
Options:Major Medical  Surgical  ASD  Loss of Use  Trip Transit

Is this:  New Business    Renewal    Additional Coverage
If renewal or additional coverage, please give current policy number:
           

Are any of the horses listed herein financed?  Yes    No
If so, please state amount, when and to whom due (please include full address):
        

Is there any other insurance on any of the horses listed
herein?  Yes    No
With whom? 
        

Are you the sole owner of this/these horse(s)? Yes    No
If no, please list other owner(s):
        

Horse(s) are chiefly kept on premises known as: 
(please give complete address of location:
        

Name of Trainer: 

Address/Phone of Trainer: 

Name of Veterinarian: 

Address/Phone of Veterinarian: 

If mare in foal, name covering stallion & stud fee paid? Yes    No
If raised foal, give stud fee: 


Have any of the above named horse(s) been afflicted with any disease
or sickness, or received any hurt or injury in the past 12 month period?
Yes    No
If so, give particulars for each named horse:

Is any horse named above to be used as a hunter/jumper/eventer or
for racing? Yes    No
If Yes, please explain use:

Are eyes, legs, and feet of every horse named above in normal
condition? Yes    No
If No, please explain:

Has any horse named above ever had colic or indigestion?
Yes    No
If Yes, how often?

When was the last attack?

Give cause of attack, if known:

How many horses did you lose by death in the last 3 years? 

Cause of death(s)?

Date of death(s)?

Insured amount paid?                How many other horses do you own?
          

Was purchase price cash, trade, or both? Cash    Trade    Both
If any part trade, please state what it consisted of, and state amount
cash was paid:

Do you understand that it is required under the policy that you must give IMMEDIATE notice by telephone of any ILLNESS, INJURY, DISEASE or DEATH or your claim may be denied?    Yes    No
Do you agree to do so?     Yes    No

Has any company ever rejected an application for insurance or cancelled a policy on any of the herein described horses?   Yes    No
If so, please explain:

Annual Rates for Horses age 30 days to 15 years:
To determine your coverage price on mortality, multiply the value of your horse by the percentage in the section you want coverage for. Other coverage rates are as stated.