ANIMAL MORTALITY RENEWAL APPLICATION HORSES ONLY

ANIMAL MORTALITY RENEWAL APPLICATION HORSES ONLY
Producer’s Name NORTHWEST INSURANCE LLC
Policy Number
Expiration Date

MonthDayYear
Date
Applicant’s Name
Address

Mail Address

Street Address Line 2

City, ST ZipState / Province

Postal / Zip Code
TYPE OF RENEWAL COVERAGE

MORTALITY-FULLMORTALITY-LIMITEDMAJOR MEDICAL $5000 LIMIT BASIC(ONLY AVAILABLE WITH HARTFORD)MAJOR MEDICAL $7500 LIMIT BAISC (ONLY AVAILABLE WITH HARTFORD)MAJOR MEDICAL $7500 LIMITMAJOR MEDICAL $10,000MAJOR MEDICAL $15,000MAJOR MEDICAL $10,000 HIGH DED (ONLY AVAILABLE WITH HARTFORD)AS&D (STALLION INFERTILITY)COLIC TREATMENT$10,000 (ONLY AVAILABLE WITH BERKLEY)INCREASE EMERGENCY COLIC $7500 (ONLY AVAILABLE WITH BERKLEY)INCREASE EMERGENCY COIC $10,000 (ONLY AVAILABLE WITH BERKLEY)TRANSIT ONLYOTHER
ANIMAL NAME AND LOCATION(CITY,STATE)
REGISTRATION NUMBER
USE OF ANIMAL(IF SHOW, LIST ALL EVENTS)
INSURED VALUE OF HORSE
IF YOU WOULD LIKE TO INCREASE VALUE OF HORSE A PLEASE LIST BELOW ALL TRAINING AND WINNINGS THE LAST YEAR.
LIST HOW MANY MONTHS AND TRAINING COSTS/ MONTH
1. Is the horse currently free of lameness and healthy without the use of drugs?

YesNo
If question #1 was NO for Horse A Please explain.
2. Has the horse been examined by a veterinarian within the last year? (ROUTINE CARE ETC...)

YesNo
If Question #2 is YES, Please explain below.
Routine care, dental exams, vaccinations etc....
3. Has the horse undergone diagnostic ultrasound, bone scan, or x-rays within the last 36 months?

YesNo
If Question #3 is YES, please explain below.
4. Has the horse been nerved or received any treatment for lameness?

YesNo
If question #4 was YES, please explain below.
5. Has the horse received any joint injections, any type of medication long or short term, or any preventative treatments in the last 36 months?

YesNo
If Question #5 was YES, Please explain below what was done and when.
6. Has the horse had any colic, colic surgery, impaction, or intestinal disorder within the last 12 months?

YesNo
If Question #6 was answered YES, please explain with incident date and severity.
7. Is the horse due to foal any time during the requested policy period?

YesNo
If question 7 was Yes Give Expected Foaling Date

MonthDayYear
Date
If question 7 was YES, list stud fee of resulting foal.
If question 7 was YES, please list number of previous foals your mare has had?
8. Has the horse shown in HYPP signs or symptoms?

YesNo
If Question #8 was YES, please explain.
IF YOU ONLY HAVE ONE HORSE PLEASE MOVE DOWN TO THE SIGNATURE PAGE.
HORSE B: ANIMAL NAME
HORSE B: REGISTRATION NUMBER
HORSE B: USE OF ANIMAL (IF SHOW, LIST ALL EVENTS)
HORSE B: Insured Value of Horse
TYPE OF RENEWAL COVERAGE FOR HORSE B

MORTALITY-FULLMORTALITY-LIMITEDMAJOR MEDICAL $5,000 BASIC(ONLY AVAILABLE WITH HARTFORD)MAJOR MEDICAL $7500 LIMIT BASIC(ONLY AVAILABLE WITH HARTFORD)MAJOR MEDICAL $7500 LIMITMAJOR MEDICAL $10,000MAJOR MEDICAL $12,500 (ONLY AVAILABLE WITH BERKLEY)MAJOR MEDICAL $15,000MAJOR MEDICAL $10,000 HIGH DED (ONLY AVAILABLE WITH HARTFORD)AS&D (STALLION INFERTILITY)INCREASE EMERGENCY COLIC $7500 (ONLY AVAILABLE WITH BERKLEY)INCREASE EMERGENCY COLIC $10,000 ( ONLY AVAILABLE WITH BERKLEY)COLIC TREATMENT $19,999 (ONLY AVAILABLE WITH BERKLEY)TRANSIT ONLYOTHER
IF YOU WOULD LIKE TO INCREASE VALUE OF HORSE B, PLEASE INCLUDE ALL TRAINING AND WINNINGS FROM THE LAST YEAR.
Please list how many months and the charge/month.
1. Is the horse currently free of lameness and healthy without the use of drugs?

YesNo
If question 1 is NO, please explain.
2. Has the horse been examined by a veterinarian within the last year?

YesNo
If question 2 was Yes, Please explain below. EX: routine care etc..
3. Has the horse undergone any diagnostic ultrasound, bone scan, or x-rays within the last 36 months?

YesNo
If question 3 was Yes, Please explain below.
4. Has the horse been nerved or received any treatment for lameness?

YesNo
If question 4 was Yes, Please explain giving date and method of treatment.
5. Has the horse received any joint injections, any type of medications long or short term , or any preventative treatments in the last 36 months?

YesNo
If question 5 was Yes, please explain giving date and what type of treatment.
6. Has the horse had any colic, colic surgery, impaction, or intestinal disorder within the last 12 months?

YesNo
If question 6 was Yes, Please give date of incident with method of treatment.
7. Is the horse due to foal any time during the requested policy period?

YesNo
If question 7 was yes Yes Give Foaling Date

MonthDayYear
Date
If questions 7 was Yes, list stud fee for the resulting foal?
If question 7 was Yes, please list how many previous foals the horse has had?
8. Has the horse shown any HYPP signs or symptoms?

YesNo
If question 8 was Yes, Please explain below.
IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO ANY INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES.
Date
Signature

Clear
(DO NOT sign and return earlier than 30 days before the Expiration Date shown above)
Should be Empty:

ANIMAL MORTALITY RENEWAL APPLICATION HORSES ONLY

IF YOU ONLY HAVE ONE HORSE PLEASE MOVE DOWN TO THE SIGNATURE PAGE.

Date