Equine Insurance Application

Equine Insurance Application

Online application for up to 2 horses. Preserve the source document's questions, fields, sections, and ordering as closely as possible. Default all fields to optional unless clearly required in the source.
Applicant Information
Requested Effective Date

MonthDayYear
Date
Name
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Fax
Coverage Selection
Full Mortality
Major Medical Limit
Surgical Limit
Contact Preference
Horse 1 Details
Horse Name
Registration Number
Date of Birth

MonthDayYear
Date
Sex
Breed
Use
Purchase Price
Purchase Date

MonthDayYear
Date
Requested Amount
Rate
Ownership Details

Other
Ownership / Lease / Finance Details
Seller's Name
Stabling Details
Distance to Veterinarian
Insurance History

Other
Insurance History Details
Billing Options

Other
Owner Signature
Primary Discipline
Competition Level
Primary Competition Name
Training Facility Name
Veterinarian Name
Veterinarian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current Health Status
Recent Health Concerns

Other
Details of Recent Health Concerns
Date of Last Veterinary Exam

MonthDayYear
Date
Medications or Supplements
Vaccinations Current?
Deworming Program
Shoeing Status
Previous Injuries or Illnesses
Date of Most Recent Injury or Illness

MonthDayYear
Date
Recovery / Outcome Details
Estimated Current Market Value
Value Justification
Purchase Documentation Available?
Registration Papers Available?
Sale or Transfer Agreement Available?
Additional Horse 1 Notes
Acknowledgment Signature
Alternative Contact Name
Alternative Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health and Value Substantiation Notes
Horse 2 Details
Horse 2 Name
Registration Number
Date of Birth

MonthDayYear
Date
Sex
Breed
Primary Use
Purchase Price
Purchase Date

MonthDayYear
Date
Requested Insurance Amount
Rate
Ownership Status

Other
Ownership / Lease / Finance Details
Seller's Name
Stabling Details
Distance to Veterinarian
Insurance History

Other
Insurance History Details
Billing Options

Other
Applicant Signature
Does the horse have any prior lameness history?
If yes, describe the lameness history
Has the horse ever had colic?
If yes, provide colic details
Has the horse ever been hospitalized?
If yes, provide hospitalization details
Has the horse ever received surgery?
If yes, describe the surgery
Is the horse currently in regular work?
Hours or Days Worked per Week
Does the horse receive regular farrier care?
Farrier Interval
Is the horse currently under veterinary care?
If yes, veterinary care details
Veterinarian Name
Veterinarian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Veterinary Clinic
Is the horse used for competition?
Competition Discipline
Competition Level
Has the horse been sold or offered for sale in the last 12 months?
If yes, sale details
Has the horse had any medical treatment in the last 12 months?
If yes, describe medical treatment
Current Estimated Value
Value Substantiation Notes
Horse 1 Health and Value Substantiation
Horse 1 health statement categories

Other
Horse 1 health statements
Veterinary history details
Veterinary care status
Primary veterinarian name
Primary veterinarian phone
Please enter a valid phone number.Format: (000) 000-0000.
Veterinary clinic address
Date of last veterinary examination

MonthDayYear
Date
Examination outcome
Examination findings
Horse 1 medical conditions

Other
Details of medical conditions
Current treatments

Other
Treatment details
Medication status
Medication names and dosage details
Surgical history for Horse 1
Surgery details
Hospitalization history
Hospitalization details
Lameness history
Lameness details
Colic history
Colic details
Laminitis history
Laminitis details
Respiratory condition history
Respiratory condition details
Neurologic condition history
Neurologic condition details
Eye condition history
Eye condition details
Skin condition history
Skin condition details
Injury history
Injury details
Preventive care status
Preventive care details
Horse 1 declared value
Declared value amount
Value currency
Value basis
Value substantiation details
Supporting documents for value substantiation

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Veterinary records attachment

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Lab results attachment

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Diagnostic imaging attachment

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Prescription or treatment records attachment

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Additional supporting details
Source document extracted notes
Applicant certification for Horse 1 health and value information
Horse 2 Health and Value Substantiation
Horse 2 health statements

Other
Horse 2 veterinary history
Horse 2 primary veterinarian name
Horse 2 veterinarian phone number
Please enter a valid phone number.Format: (000) 000-0000.
Horse 2 veterinarian clinic
Horse 2 last veterinary exam date

MonthDayYear
Date
Horse 2 medical conditions

Other
Horse 2 details of medical conditions
Horse 2 current medications

Other
Horse 2 medication details
Horse 2 recent treatments or procedures

Other
Horse 2 treatment details
Horse 2 hospitalization history

Other
Horse 2 hospitalization details
Horse 2 lameness history

Other
Horse 2 lameness details
Horse 2 colic history

Other
Horse 2 colic details
Horse 2 respiratory history

Other
Horse 2 respiratory details
Horse 2 skin or allergy history

Other
Horse 2 skin or allergy details
Horse 2 eye condition history

Other
Horse 2 eye condition details
Horse 2 neurological history

Other
Horse 2 neurological details
Horse 2 reproductive history

Other
Horse 2 reproductive details
Horse 2 vaccines current
Horse 2 vaccine details
Horse 2 deworming current
Horse 2 deworming details
Horse 2 dental care current
Horse 2 dental care details
Horse 2 insured value requested
Horse 2 value basis
Horse 2 purchase price amount
Horse 2 purchase date

MonthDayYear
Date
Horse 2 value substantiation details
Horse 2 supporting documents

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Horse 2 document description
Horse 2 additional health remarks
Horse 2 attending veterinarian
Horse 2 attending veterinarian contact
Please enter a valid phone number.Format: (000) 000-0000.
Horse 2 illness or injury onset date

MonthDayYear
Date
Horse 2 diagnosis and prognosis
Horse 2 veterinary attestation signature
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