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  • Equine Insurance Application Form

    *All information entered below will be encrypted and not stored in any location per our electronic data safety protocol. The information will only be used in preparation of your requested proposal for insurance products. Our company electronic privacy data safety pactices are on file in our office per local, state and federal laws and industry requirements. They can be provided for your review by written request.*
  • Format: (000) 000-0000.
  • Entity Type*
  • Proposed Effective Date
     - -
  • New Policy*
  • Installment Payment Plan

  • 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)

  • Please Complete for Animal 1

    All Limits are subject to company approval.

  • If the Requested Limit of Insurance does note equal the Purchase Price, complete and upload a Substantiation of Value.

  • Animal 1 Requested Limit equal to Purchase Price?*

  • Click: Link to Substantiation of Value

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  • Animal 1 Sex*
  • Animal 1 Sire/Dam*
  • Animal 1 Registered*
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  • Animal 1 Stabled at Owner's Address*
  • Do you have another horse to insure?*

  • Please Complete for Animal 2

    All Limits are subject to company approval.

  • If the Requested Limit of Insurance does note equal the Purchase Price, complete and upload a Substantiation of Value.

  • Animal 2 Requested Limit equal to Purchase Price?*

  • Click: Link to Substantiation of Value

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  • Animal 2 Sex*
  • Animal 2 Sire/Dam*
  • Animal 2 Registered*
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  • Animal 2 Stabled at Owner's Address*
  • Animal 1 Pre-purchase Exam*
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  • Animal 2 Pre-purchase Exam*
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  • Animal 1

    Health Information

  • Following questions can also include, but are not limited to:  laminitis/founder, OCD, neurological disorders (e.g. EPM), navicular disease, and/or degenerative joint disease.

  • Animal 1 Examined/Treated by a Vet for accident, injury, sickness, disease, lameness, or any physical or neurological disorders WITHIN PAST YEAR?*
  • Animal 1 CURRENTLY FREE of lameness and healthy without use of drugs?*
  • Animal 1 Undergone diagnostic ultrasound, bone scan, or x-rays in PAST 36 MONTHS?(does not include pregnancy checks)*
  • Animal 1 EVER Examined/Treated by a Vet for ANY PAST conformational problems or defects, accident, injury, sickness, disease, lameness, or any physical or neurological disorders?*
  • Animal 1 Nerved or received any treatment for lameness?*
  • Animal 1 Received any joint injections, any long or short-term medication, or any preventative maintenance in the PAST 36 MONTHS?*
  • Animal 1 had any colic, colic surgery, impaction, or intestinal disorder within the PAST 36 MONTHS?*
  • Animal 1 due to foal anytime during policy period?*
  • Animal 1 Estimated Foaling Date*
     - -
  • Animal 1 Experienced birthing difficulties in past?*
  • Animal 1 Have an ancestor known to carry HYPP?*
  • Animal 1 Been tested for HYPP?*
  • Animal 1 Test Positive HYPP?*
  • Animal 1 Sire/Dam Test Positive HYPP?*
  • Animal 1 Show Signs or Symptoms of HYPP?*

  • Animal 2

    Health Information

  • Following questions can also include, but are not limited to:  laminitis/founder, OCD, neurological disorders (e.g. EPM), navicular disease, and/or degenerative joint disease.

  • Animal 2 Examined/Treated by a Vet for accident, injury, sickness, disease, lameness, or any physical or neurological disorders WITHIN PAST YEAR?*
  • Animal 2 CURRENTLY FREE of lameness and healthy without use of drugs?*
  • Animal 2 Undergone diagnostic ultrasound, bone scan, or x-rays in PAST 36 MONTHS? (does not include pregnancy checks)*
  • Animal 2 EVER Examined/Treated by a Vet for ANY PAST conformational problems or defects, accident, injury, sickness, disease, lameness, or any physical or neurological disorders?*
  • Animal 2 Nerved or received any treatment for lameness?*
  • Animal 2 Received any joint injections, any long or short-term medication, or any preventative maintenance in the PAST 36 MONTHS?*
  • Animal 2 had any colic, colic surgery, impaction, or intestinal disorder within the PAST 36 MONTHS?*
  • Animal 2 due to foal anytime during policy period?*
  • Animal 2 Estimated Foaling Date*
     - -
  • Animal 2 Experienced birthing difficulties in past?*
  • Animal 2 Have an ancestor known to carry HYPP?*
  • Animal 2 Been tested for HYPP?*
  • Animal 2 Test Positive HYPP?*
  • Animal 2 Sire/Dam Test Positive HYPP?*
  • Animal 2 Show Signs or Symptoms of HYPP?*

  • YOU'RE ON THE FINAL STRETCH!

  • Will the horses be observed and cared for daily?*
  • Are you sole owner of horse(s)?*
  • Are horse(s) leased to others?*
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  • Any other insurance on the horse(s)?*
  • Has any insurance carrier ever canceled, non-renewed, or refused to insure any horse in which you have or had an insurable interest?*
  • Have you lost any horse (insured or not) in the PAST 5 YEARS or have filed any med/surgical/colic claims on listed horse(s)*
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