• OWNER / INSURED INFORMATION

  • Format: (000) 000-0000.
  • Requested Effective Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this horse currently insured?*

  • HORSE INFORMATION

  • Sex:*
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • VALUE & COVERAGE

  • Date Purchased: *
     - -
    2 digit month, 2 digit day, 4 digit year
  • How was the current value determined?*
  • Coverage Options:*

  • USE OF HORSE

  • Primary Use:*

  • HEALTH & VETERINARY HISTORY

  • Is the horse currently health and free from illness, injury, lameness, or abnormality?*
  • Has the horse ever had a significant illness, injury, surgery, colic, lameness, or other medical condition?*
  • Any current medications or ongoing treatments?*
  • Date of last veterinary exam:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Veterinary records available if requested?*

  • ADDITIONAL INFORMATION

  • Are there any previous insurance claims or mortality losses involving this horse?*

  • Confirm and Sign

  • I certify that the information provided is true and complete to the best of my knowledge. I understand that completion of this form does not provide insurance coverage or guarantee acceptance.

    Additional information and documents may be required, such as: Bascule Equine Mortality Application, Declaration of Health, Veterinary Certificate / Exam, Registration Papers, Purchase Agreement / Bill of Sale, Documentation supporting Requested Value, or other underwriting documentation.

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

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