Colic Assurance Plan Enrollment Form

This program is designed to offer a colic reimbursement benefit to long-term users of the Assure/Secure System digestive products. Unlike other plans, the enrollment is personalized, coverage includes medical as well as surgical colic situations and offers allowances for horses who have previously suffered from colic. Enrolled horses are eligible for a lifetime benefit of up to $15,000. Qualifying Assure/Secure System products may be purchased directly from Arenus, your veterinarian or through a select Arenus dealer.

Please visit our website and review the full program details prior to completing this enrollment form.

Program Requirements:

Completed enrollment form
Adherence to feeding guidelines associated with the Wellness Program your horse is assigned
Previous 1 year of veterinary medical records showing annual exam, veterinary administration of vaccines and compliance with veterinary-directed deworming program (please review Terms & Conditions for full information regarding annual requirements while enrolled)
Completion of all claim requirements if/when a claim is filed
Maintain regular purchases of qualifying Assure/Secure System products in compliance with your designated Wellness Program and maintain records of these purchases
Purchase and shipment of qualifying Assure/Secure System products within 48 hours prior to enrollment form completion or 5 days after acceptance into the Colic Assurance Program
Adherence to and proof of completing the Annual Wellness Requirements

This enrollment form is to be completed by the owner, agent or lessee of the horse.

**If you are enrolling multliple horses in the program, please allow at least 30 minutes between submitting each horse for enrollment.

Owner First Name:

Owner Middle Name:

Owner Last Name:

Owner Street Address

Owner Street Address Line 2

Owner City

Owner State/Province

Owner Zip Code

Owner E-mail:

Owner Phone Number (primary):

Area CodePhone Number

Owner Phone Number (secondary):

Area CodePhone Number

Will the main contact for this horse be an agent (trainer, lessee, etc.)?

Agent Type

If "Other" Agent Type, Please Describe

Agent First Name:

Agent Last Name:

Agent Street Address

Agent Street Address Line 2

Agent City

Agent State/Province

Agent Zip Code

Agent E-mail:

Agent Phone Number (primary):

Area CodePhone Number

Agent Phone Number (secondary):

Area CodePhone Number

How did you hear about the Colic Assurance Program?

Which Arenus representative referred you?

Where will you be purchasing qualifying Colic Assurance Program products after your initial purchase?

Is your billing address different from the address listed above?

Billing Street Address

Billing Street Address Line 2

Billing City

Billing State/Province

Billing Zip Code

Will you be shipping products to a different location than the address given above?

Shipping Street Address

Shipping Street Address Line 2

Shipping City

Shipping State/Province

Shipping Zip Code

Is this Horse Registered?

Registration Organization

Registration Number

Horse's Registered Name

Horse's Nickname

Breed

Age (years)

Height (i.e. 15.2)

Color

Sex

Approximate Weight (pounds)

Approximate Exact Weight (pounds)

Upload a photo of your horse. This photo is required and meant for identification purposes to accompany their lifetime health record with Arenus. Please upload a photo that meets these specifications:

No tack, blankets, wraps or boots
Includes the entire body of the horse, not just the head
Clearly shows the horse's color and markings
Acceptable photo formats are: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

The submitted photo should be similar to that used for Coggins papers.

Upload Horse Photo

Upload a File

Horse Stable Street Address

Horse Stable Street Address Line 2

Horse Stable City

Horse Stable State/Province

Horse Stable Zip Code

What is this horse's primary job? (i.e. jumping, trail riding, etc.)

How often is this horse exercised?

At what level is this horse excercised regularly?

When this horse travels, what are the most common destinations? Check all that apply.

How often does this horse travel?

This horse is primarily housed in a:

What type of forage does this horse receive (check all that apply)?

Amount of grass hay fed per day (flakes):

Amount of grass hay fed per day (pounds):

Amount of alfalfa hay fed per day (flakes):

Amount of alfalfa hay fed per day (pounds):

Amount of grass/alfalfa mix hay fed per day (flakes):

Amount of grass/alfalfa mix hay fed per day (pounds):

How many hours per day does this horse spend grazing on pasture grass?

Forage Feeding Schedule:

Does this horse receive a concentrate (grain) in their daily ration as well?

What type of concentrate does this horse eat (brand, name, etc.)?

How many pounds of concentrate does this horse receive daily?

Concentrate feeding schedule:

What other supplements and/or medications is this horse receiving daily?

Your primary care veterinarian is the veterinarian that will perform your Annual Wellness Requirements.

Veterinarian First Name

Veterinarian Last Name

Clinic Name

Veterinarian Street Address

Veterinarian Street Address Line 2

Veterinarian City

Veterinarian State/Province

Veterinarian Zip Code

Veterinarian/Clinic Email

Veterinarian/Clinic Phone Number

Area CodePhone Number

Has this horse colicked before?

How many times has this horse colicked in the past 12 months?

Has this horse ever been diagnosed with having a lipoma(s)?

Has this horse ever been diagnosed with having an entrolith(s)?

Has this horse ever received abdominal surgery (for colic or other medical condition)?

Date of Abdominal Surgery

MonthDayYear

Name of Attending Veterinarian

Clinic Name

Clinic Street Address

Clinic Street Address Line 2

Clinic City

Clinic State/Province

Clinic Zip Code

Clinic Phone Number

Area CodePhone Number

Reason for Abdominal Surgery:

If colic surgery, please describe type of colic

Has this horse had more than one abdominal surgery?

Note: If your horse has had more than one abdominal surgery in the past, you may be asked to provide additional information before enrollment into the Colic Assurance Program.

Date of 2nd Abdominal Surgery

MonthDayYear

Date of 3nd Abdominal Surgery

MonthDayYear

Do you have access to the past 1 years worth of medical records?

If no, do you understand that these records will be required if a claim is made?

Upload previous 12 months of veterinary medical records (optional at this time):

Upload a File

The Colic Assurance Program offers two unique Wellness Programs, one of which your horse will be assigned to based on their completed application. Within each Wellness Program, there are two supplementation options that you will need to choose from.

You can choose to use the system approach and feed Assure Guard and Assure Plus OR use the single product approach and feed Assure/Secure Guard Gold. Both supplementation options provide excellent coverage for colic and condition the digestive tract to work optimally.

Please review the supplementation protocols below for each Wellness Program and choose your supplementation option. Must have adminstrator approval to change supplemenation option.

Your chosen qualifying product option:

Proof of Purchase (see above):

Browse Files

Once enrolled, you are required to make a qualifying product purchase within 5 days of receiving your enrollment confirmation email. Purchases made within 48 hours of submitting this form (either from your veterinarian or Arenus Animal Health) are valid. Purchases made prior to the 48 hour window will not qualify as the required initial purchase.

If you purchased within the 48 hours prior to completing this form, please upload your receipt using the file attachment below. If you plan to purchase from your veterinarian (or other qualified retailer) once you've received your enrollment confirmation, please email your receipt to advisor@colicassurance.com

You are also required to complete the loading dose within your assigned Wellness Program once enrolled. You will receive your assigned Wellness Program via email once you have enrolled in the program. This is required of ALL horses enrolled in the Colic Assurance Program regardless of previous history with the Assure products.

I have read and understand the statement above.

The Colic Assurance Program (CAP) is a reimbursement program for owners of horses that are currently using the Assure/Secure System digestive aid products. There are requirements for enrollment and product use as well as horse history and a claim process must be adhered to. All claims are subject to a medical review for accuracy of information and situations. There are certain exclusions and limitations that should be reviewed before relying on this reimbursement program. Our goal is not to exclude claims, but to be certain they meet program requirements and help your horse remain colic free.

Please review this form for completion and accurancy as well as the full Colic Assurance Program information and Terms & Conditions before submitting your enrollment form.

Upon signing below and submitting your completed enrollment application, you agree to adhere to the full terms, requirements and restrictions associated with the Colic Assurance Program.

I have read and understand the full terms and conditions of the Colic Assurance Program. I understand that by signing and submitting below that I am agreeing to the term and conditions of the Colic Assurance Program.

Signature

Printed Name

First NameLast Name

Signature Date

MonthDayYear

**If you are enrolling multliple horses in the program, please allow at least 30 minutes between submitting each horse for enrollment.

Browse Files

Enrollment Form

Owner/Agent Information

Billing & Shipping Information

Horse Information

Current Nutrition Information

Primary Care Veterinarian Information

Medical History

Qualifying Product Selection

Terms & Conditions