AEIG Equine Mortality Application

Equine Mortality Application
Name and Address of Applicant:
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Desired Effective Date:
Broker:
Broker License Number:
◆ Approval of date by Company is subject to receipt of application, satisfactory underwriting information, and required health information.

Rows	Breed	Sex*	Height	Exact Use / Level	Date of Birth	Purchase Date	Purchase Price	Insured Amount**
A.
B.
C.
D.

*G-Gelding, M-Mare, S-Stallion
** If requested value exceeds purchase price, please provide value substantiation on next page. Insured amount should not exceed the horse's current fair market value. Please note that a recent purchase cannot be insured for more than the purchase price.
Mortality coverage desired: Horse:
Full Mortality Coverage (including Free Colic Surgery coverage*, Guaranteed Extension, Value Endorsement) – Subject to policy wording Named Perils Coverage
Please check additional coverages desired. Additional premium is required.
Horse:
Equine Catastrophic Accident and Illness (annual limit $5,000)
Equine Medical and Surgical (annual limit $7,500)
Equine Medical and Surgical (annual limit $10,000)
Equine Medical and Surgical (annual limit $15,000)
Surgical Only
Full Loss of Use (Plan A)
External Injury Only Loss of Use (Plan B)
Stallion Infertility for A, S & D
Third Party Liability
Territorial Limits Including Transit (Must complete question 18 below.)
1. Are you the sole owner of the horses? If not, list owners, other party, bank or lienholder to be named on the policy.
2. Are the horses healthy and sound for the use intended without the use of medications?
3. For all Quarter Horses, Appaloosas, or Paint horses. Does any horse have an ancestor known to carry HYPP? Please indicate:
If "Yes" please indicate the HYPP status (N/N, N/H, H/H) for each horse. (Note: Coverage will not be considered without the disclosure of HYPP status.)
4. Has any horse had any past or present conformation problems, defects or ailments, illness or disease, lameness, injury or physical disability including but not limited to: OCD, neurological disorders, navicular disease, and/or degenerative joint disease? If yes, please provide detailed explanation.
5. Has any horse been nerved or received any surgical treatment for lameness? If yes, explain.
6. Has any horse had any colic or intestinal disorder past or present? If yes, explain.
7. Has any horse been examined or treated by a veterinarian for anything other than routine care? If yes, explain.
8. Has any horse undergone diagnostic ultrasounds, X-rays, or bone scans? If yes, why, and what were the results?
9. For horses valued over $100K was a pre-purchase exam performed within the last 14 months? If so, please submit a copy with your application.

10. Has any horse received any joint injections? If yes, please specify joints injected, dates, and reasons for injections.
11. Has any horse received any type of medication long or short term, or any preventative treatments in the last 12 months? If yes, please provide detailed explanation.
12. Does any horse receive any other medications/supplements? If yes, please provide detailed explanation.
13. Has any horse been treated for hoof problems, founder/laminitis, or rotation of the coffin bone?
14. Is there now any contagious or infectious disease on the premises, or has there been during the past 12 months?
15. Name of previous Insurance Company, if any. If coverage is still in place, please provide the expiration date to avoid duplicate coverage.
16. Has any insurer ever declined, imposed restrictions, or refused to renew your horse insurance? If yes, give details. (Not applicable in Missouri.)
17. Have you filed insurance claims in the past three years for any of the proposed horses? If yes, please state name of company, name of horse, and amount paid.
18. Will any horse be outside the contiguous United States or Canada during the coverage period? If yes, give details including dates and locations for coverage consideration. (Note: If any horse may later travel outside the continental United States or Canada, the company needs prior written notification for coverage consideration.)
VALUE SUBSTANTIATION SHOW RESULTS FOR LAST 12 MONTHS - Include show ratings / level and winnings where applicable. If applicable, include USEF registration # and/or breed registration #. Attach separate sheet if necessary.
TRAINING RECORD - Description of additional training the horse has received since purchase. Please specify name of trainer, dates in training, and charge per month, not including board, vet, farrier, or other charges. Please specify the horse's current capabilities. Attach separate sheet if necessary.
STALLION QUESTIONS - If AS&D coverage is also desired, please complete the Stallion AS&D Supplemental Application. Please provide current stud fee, mares bred last full season, mares booked for current season, and bookings for next season. Also include average sales price of offspring, and offspring performance records. Attach separate sheet if necessary.
BROODMARE QUESTIONS - Please provide stallion bred to, due date, year of last foaling, and foaling record. Also include average sales price of offspring, and offspring performance records. Attach separate sheet if necessary.
FOAL / YEARLING / YOUNG HORSE QUESTIONS - Please provide sire / dam, stud fee of sire, and sale prices and/or performance records of full / half siblings. Attach separate sheet if necessary.
Additional information or comments:

GENERAL FRAUD STATEMENT
(Not applicable in the states mentioned below where a specific warning applies.)
Any person who knowingly and with intent to defraud any insurance company or other 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, and may be subject to a civil penalty or fine.
Alabama - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.
Arkansas, District of Columbia, Louisiana, Rhode Island, West Virginia - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Colorado- It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies
Florida - Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kansas - An act committed by 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, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or 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.
Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.
Maine - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Maryland - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey, New Mexico - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York - Any person who knowingly and with intent to defraud any insurance company or other 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon - Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties.
Tennessee, Virginia, 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.
DECLARATION
DO NOT SIGN THIS APPLICATION UNTIL YOU HAVE READ ALL OF ITS CONTENTS AND THE APPLICABLE FRAUD WARNING(S): Your intentional failure to disclose any material information that could reasonably result in a claim may result in the insurance policy/coverage that you are applying for being subject to cancellation. If any of the material information in this application has been intentionally falsely stated by you or if material information has intentionally not been disclosed by you which may influence the Company's underwriting decision, any insurance policy/coverage issued to you by the Company may be subject to cancellation. The fraud or misrepresentation must be made with the intent to deceive.
I/We, the undersigned, am/are applying to insure the above mentioned horse(s). I/We confirm to the best of my/our knowledge and belief that the above statements are true, complete and correct, and that I/we have disclosed all material information. I/We acknowledge that this application is not a binder of insurance coverage or an insurance policy. I/We acknowledge my/our completion of this application does not obligate me/us to purchase an insurance policy/coverage from the Company. I/We also acknowledge that my/our operation may be subject to inspection by the Company or its authorized representative.
Signature of applicant(s) of above named horse(s)
Date:

MonthDayYear
Date
(must be no more than 30 days prior to policy effective date)
Broker signature (required in NH)
Date:

MonthDayYear
Date
(must be no more than 30 days prior to policy effective date)
Should be Empty:

Equine Mortality Application

GENERAL FRAUD STATEMENT

DECLARATION