Claim Initiation Form

Colic Episode Report Form
To be completed by the owner or agent of the enrolled horse within 14 days of the colic episode. For full details, please review the Colic Assurance Program Terms & Conditions.

This form does not file a claim for reimbursement. Please follow this link to file a claim: arenus.com/file-a-claim/
General Information
Owner First Name*
Owner Last Name*
Owner Phone Number*

Area CodePhone Number
Owner E-mail*
Owner Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Horse's Name*
CAP Enrollment Number
Is there a main contact for this report other than the horse owner?*

YesNo
Colic Episode Information
Date of Colic Episode:*

MonthDayYear
Has treatment been completed for this colic episode?*

YesNo
Did this colic episode require surgery to resolve?*

YesNo
Will you be filing a claim for reimbursement for this colic episode?*

Yes*No
* If you elect to file a claim for reimbursement for this colic epsidoe, you must initiate a claim within 14 days of colic resolution. This form does not file a claim for reimbursement. Please follow this link to file a claim: arenus.com/file-a-claim/
Primary Care Veterinarian *

First NameLast Name
Primary Care Veterinarian Phone Number

Area CodePhone Number
Attending Veterinarian:*

First NameLast Name
Attending Veterinarian Phone Number:

Area CodePhone Number
Brief summary of colic episode: *
Terms & Conditions
I attest that this horse has met all of the Colic Assurance Program annual requirements, including exams, vaccinations and deworming (once yearly with praziquantel and once yearly with either moxidectin or a 5 day double dose of fenbendazole, and one fecal egg count test).*

YesNo
By signing below, I certify that the information listed above is both complete and accurate. Additionally, I have read and understand the full Terms & Conditions of the Colic Assurance Program.

I understand that I must submit the claim initiation form within 14 days of the qualified horse's colic episode to file a claim for reimbursement for this colic episode.
Signature*

Clear
Printed Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Colic Episode Report Form

General Information

Colic Episode Information

Terms & Conditions