Animal Mortality Application for Horses

Name Insured

Agency Code

Mail Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

E-mail Address

Applicant's Name *

First Name Last Name

Mail Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Fax Number

Area Code Phone Number

E-mail Address

Policy Term Desired *

(maximum term 12 months)

New Policy

Legal Entity *

Individual Partnership Corporation Joint Venture

Proposed Effective Date

Month Day Year

Installment Payment Plans? *

Yes No

Animal Information *

	Horse A	Horse B
Animal Name
Date of Birth
Date of Purchase
Purchase Price (or stud fee if raised)
Requested Limit of Insurance
Identification
Sex (Stallion, Mare, Colt,Filly, Gelding)
Breed
Use
Primary Stable Location

All Limits of Insurance are subject to company approval.

Does the Requested Limit of Insurance equal the Purchase Price?

Yes No

If no, complete and attach a Substantiation of Value form.

Type of Coverage Requested *

	Horse A	Horse B
Mortality - Full
Mortality - Limited
Renewal Protection
Major Medical $5,000, Basic
Major Medical $7,500, Basic
Major Medical $7,500
Major Medical $10,000
Major Medical $15,000
Major Medical $10,000 high deductible
Accident, Sickness and Disease
Loss of Use
Loss of Use - Limited
Surgical $5,000 Limit
Aggregate Deductible
Other

Medical Conditions *

	A - Yes	A - No	B - Yes	B - No
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 treatments 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 to #9, please give:

Estimated Foaling Date:

Number of Previous Foals:

Stud Fee:

*

	A - Yes	A - No	B - Yes	B - No
10. Has the horse ever experiences birthing difficulties? (Mares only)
11. Does the horse have an ancestor known to carry HYPP? If No, please move on to question 12.

*

	A - Yes	A - No	B - Yes	B - No
10. Has the horse ever experiences birthing difficulties? (Mares only)
11. Does the horse have an ancestor known to carry HYPP? If No, please move on to question 12.

If Yes to #11, please answer:

	N/N - A	N/N - B	N/H - A	N/H - B	H/H - A	H/H - B
11a. Has the horse been HYPP tested? If Yes, please check the test results.
11b. Please check the HYPP test results of the horse's SIRE.
11b. Please check the HYPP test results of the horse's DAM.

	A - Yes	A - No	B - Yes	B - No
11c. Has the horse ever shown any HYPP signs or symptoms?

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) *

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 and 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. Primary Licensed Veterinarian *

First Name Last Name

Veterinarian's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Veterinarian's Phone Number *

Area Code Phone Number

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 the 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 vet exam)

Please Upload Any Necessary Documents

NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THE APPLICATION FOR INSURANCE. 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. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.

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 (NY; SUBSTANTIAL) CIVIL PENAL TIES. (Not application in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WZ; 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 DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF FALSE 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 AN APPLICATION 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 OR BELIEF 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 A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING 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 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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A 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 OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

Applicant's Initials *

Date (Must be no more than 30 days prior to policy effective date) *

Month Day Year

Producer's Initials *

Producer's Name *

State Producer License No. *