ANIMAL MORTALITY APPLICATION for HORSES
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  • ANIMAL MORTALITY APPLICATION for HORSES

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  • Proposed Effective Date
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  • Pay Plan
  • (Coverage begins on the date of acceptance by the Company)
  • PLEASE READ: If you submit an INACCURATE an and/or INCOMPLETE Application, the missing inormation will delay your coverage and the inaccurate information will result in claim denials and/or coverage reductions. The insurance you are applying for with this Application DOES NOT and WILL NOT cover Pre-Exiting Conditions.
  • Date of Birth
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  • Date of Purchase
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  • *All Limits of Insurance are subject to company approval
    *For a Requested Limit of Insurance that does not equal the Purchase Price, complete and attach
    Substantiation of Value.

     

  • Type of Coverage Requested

  • 1. Was a pre-purchase exam completed? If yes, please attach a copy of the examination results
  • 2. Has the horse been examined or treated by a veterinarian for any accident, injury, sickness disease, and or lameness within the last 24 months? If Yes, please explain
  • 3. Is the horse currently free of lameness and healthy without the use of drugs? If No, please explain
  • 4. Has the horse undergone an ultrasound, bone scan, gastroscope, or x-rays within the last 24 months? If Yes, please explain
  • 5. Does the horse have any past conformational problems or defects, illness or disease, lameness, injury, or physical disability including but no limited to: laminitis/founder, OCD, neurological disorders (e.g. EPM), navicular disease, kissing spine, arthritis, and/or degenerative joint disease? If Yes, please explain
  • 6. Has the horse and a neurectomy or received any treatment for lameness? If Yes, please explain
  • 7. Has the horse received any long-or short-term medication or any preventative treatments in the last 24 months? If Yes, please explain
  • 8. Had the horse received any joint injections in the last 24 months? If Yes, Which Joints? How Often? Names of Meds?
  • 9. Has the horse had any colic, colic surgery, inpaction, gastric ulcers, or intestinal disorder with the last 24 months? If Yes, please explain

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  • 10. If a mare, is the mare due to foal any time during the requested Policy Period?
  • Estimated Foaling Date:
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  • 11. If a mare, has the mare ever experienced birthing difficulties? If Yes, please explain
  • 12. Does the horse have an ancestor know to carry HYPP? If Yes, please check the test results; If No, please move on to question 13.
  • a. Has the horse been HYPP tested? If Yes, please check the test results.
  • Sire: HYPP RESULTS OF HORSES SIRE
  • Dam: HYPP RESULTS OF HORSES DAM
  • c. Has the horse ever shown any HYPP signs or symptoms?
  • 13. Will the horse be observed and cared for daily
  • 15. Are you the sole owner of the horse? If No, provide owner's % Interest, name and address.
  • 17. Method of Payment
  • 18. Is the horse leased? If Yes, please include the lease agreement in separate email.
  • 19. Is there or has there ever been any insurance on the horse that is similar to any insurance available on this Application
  • 20. Has any insurance carrier ever canceled, non-renewed or refused to insure an horse(s) in which you have or had a insurable interest?
  • 21. Have you lost any horse in the last 5 years (whether insured or not) or have any medical/surgical or colic claims been filed on the above listed horse?
  • 23. Do you understand that the insurace 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 a claim?
  • 27. Is horse currently up to date on worming and vaccinations as recommended by a Vet?
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  • COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)
  • NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU INCONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY USOR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEWYOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS ANDOUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMITA REQUEST TO US.
  • ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
  • IN THE DISTRICTOF 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, IFFALSE 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 ANAPPLICATION 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 ORBELIEF 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, ORACLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCEWHICH SUCH PERSON KNOWS TOCONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATIONCONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENTINSURANCE ACT. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY ORANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FORTHE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BEA 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 OFDEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
  • THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HERKNOWLEDGE.
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