Insured Name | Contact *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

#1. Is the horse currently sound and healthy for intended use? *

Yes

No

#2. Does a listed horse have any past structural problems or defects, illness or disease, lameness, injury, or physical disability that could affect its ability to be used for the intended purpose? *

Yes

No

#3. Has a listed horse received any type of medication (long or short term) for anything other than preventative treatment in the last 24 months? If so, please list below. *

Yes

No

#4. Has a listed horse been examined or treated by a veterinarian for anything other than routine care within the past 12 months? *

Yes

No

#5. Has a listed horse had any gastro-intestinal disorder within the last three (3) years? *

Yes

No

#6. Has a listed horse undergone surgery (other than castration)? *

Yes

No

#7. If a listed horse is a breeding female, has she ever experienced birthing difficulties? *

Yes

No

Are there any other facts within your knowledge not already disclosed affecting or likely to affect the Company's acceptance of the proposed risk? *

Yes

No

Date

MM

DD

YYYY