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Equine Application Form

Fill out our equine application form to get started. Receive your horse insurance quote quickly and easily!

Let’s Get Started

Step 1Fill out the form.
Step 2Review your options with us.
Step 3Get the coverage you need.

"*" indicates required fields

Applicant Name*

First Name* Last Name*

Email*

Phone Number*

Address*

Street Address* Address Line 2 City* State/Prov./Region* ZIP/Postal*

Requested Effective Date:*

MM slash DD slash YYYY Requested Effective Date:*

Coverage:*

Mortality Theft

Specified Perils

Horse(s) to be Insured

Amounts other than purchase price are subject to Company acceptance. Please provide explanation of value.

Horse 1

Name*

Breed*

Year Born (DOB)*

Sex*

(Colt, Filly, Gelding, Mare, Stud)

Amount Insured*

Ownership %*

Use*

Date Purchased*

MM slash DD slash YYYY Date Purchased*

Purchase Price*

Major Medical*

$7,500

$10,000

$15,000

Additional Coverage Options

Increase Colic Surgery by $7,500

Stalliion Permanent Disability

Would you like to add another Horse?*

Yes

Horse 2

Name*

Breed*

Year Born (DOB)*

Sex*

(Colt, Filly, Gelding, Mare, Stud)

Amount Insured*

Ownership %*

Use*

Date Purchased*

MM slash DD slash YYYY Date Purchased*

Purchase Price*

Major Medical*

$7,500

$10,000

$15,000

Additional Coverage Options

Increase Colic Surgery by $7,500

Stalliion Permanent Disability

Do you own any other Horses you'd like insured?*

Yes

Are you the sole owner of the horse(s)?*

Yes

List owners and address or lienholders/banks and address*

Usual location of Horse(s), give address and phone number:*

Is horse(s) on a vaccination and worming program approved by a veterinarian?*

Yes

Frequency*

Is there any contagious or infectious disease on the premises, or has there been during the past twelve (12) months?*

Are horse(s) presently or previously insured?*

Yes

Please provide the company name, date, and amount(s)*

Has any company cancelled or refused to renew your coverage?*

Yes

Please state number of deaths and causes of death*

Has any horse(s) owned by you died with the past 36 months whether insured or not?*

Yes

If yes, give reason*

Declaration of Health

At the inception of the policy, all horses must be sound, healthy, and have no known injury, illness, lameness, or disease. Any pre-existing conditions are not covered, unless otherwise noted and agreed to by the company.

HORSE 1: Does a listed horse have any history of injury, illness or disease?*

Yes

HORSE 2: Does a listed horse have any history of injury, illness or disease?*

Yes

HORSE 1: Does a listed horse have any nay 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

HORSE 2: Does a listed horse have any nay 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

HORSE 1: Has a listed horse received a type of medication (long or short term) for anything other than preventative treatment I the last twenty-four (24) months? If so, please list below.*

Yes

HORSE 2: Has a listed horse received a type of medication (long or short term) for anything other than preventative treatment I the last twenty-four (24) months? If so, please list below.*

Yes

HORSE 1: Has a listed horse been examined or treated by a veterinarian for anything other than routine care in the past twelve (12) months?*

Yes

HORSE 2: Has a listed horse been examined or treated by a veterinarian for anything other than routine care in the past twelve (12) months?*

Yes

HORSE 1: Has a listed horse had any other gastro-intestinal disorder within the past three (3) years?*

Yes

HORSE 2: Has a listed horse had any other gastro-intestinal disorder within the past three (3) years?*

Yes

HORSE 1: Has a listed horse undergone surgery (other than castration)?*

Yes

HORSE 2: Has a listed horse undergone surgery (other than castration)?*

Yes

HORSE 1: If a listed horse is a breeding female, has she ever experienced birthing difficulties?*

Yes

HORSE 2: If a listed horse is a breeding female, has she ever experienced birthing difficulties?*

Yes

HORSE 1: 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

HORSE 2: If a female, is she pregnant? If yes, give last service date and due date:*

Yes

HORSE 1: If a female, is she pregnant? If yes, give last service date and due date:*

Yes

HORSE 2: 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

If yes was answered to any question(s) other than question 8 above, please provide an explanation below. Include onset date, diagnosis, treatment how condition was resolved and when horse(s) returned to full work.

Disclaimer: The proposed insured affirms that the foregoing information is true and agrees that this application shall constitute a pare to a policy issued whether attached or not and any willful concealment of misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy.

I declare to the best of my knowledge and belief that the animal(s) listed on the above application are in normal healthy sound condition. I hereby certify that the above information is truthful and accurate. I understand that any fraudulent, omited, or misrepresented statement voids any policy of insurance issued on the basis of this application, I hereby understand that the insurance being applied for, if accepted by the Company, will be based on statements made in this application.

I understand and agree this is not a binder, but merely an application for insurance. I also understand that it is required under the policy to five immediate notices by telephone of any illness, injury, disease of death of any insured animal. Not doing so may jeopardize coverage and result in denial of any claim made.

Digital Signature:*

Date:*

MM slash DD slash YYYY Date:*

If animal(s) is ever leased to others, please provide a copy of the lease agreement with this application

Payment Options:

Full annual payment

2 installments - if premium is greater than $500

4 installmetns - if premium is greater than $1,000

This field is for validation purposes and should be left unchanged.

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