Austbrokers Bloodstock,

A Trading Name of Austbrokers Sydney Pty Ltd

ABN 14 061 968 090

AFS Licence No. 244244

9 Gloucester Road Hurstville NSW 2220

PO Box 103 Hurstville NSW 1481

Tel (02) 9570 8355 Fax (02) 9586 1467

Website: www.bloodstockinsurance.com.au

Email:

Prospective Foal Insurance Proposal Form

PERIOD OF INSURANCE
Effective ___ / ___ / ____ To: 30 days after birth [ ] OR 12 Months after birth [ ]
PROPOSER
Owners Full Name ______
Postal Address: ______
______Post Code ______
Phone (Work) ( ) ______(Home) ( )______(Mobile) ______
Email Address: ______
FOALING HISTORY
YEAR / DETAILS
This Year
Last Year / SEE ATTACHED BREEDING RECORD FROM AUSTRALIAN STUD BOOK
Previous Year
DETAILS OF MARE
Name Of Mare ______Colour ______Foaled ______
Sire ______Dam ______
Mare Served By ______Date of Last Service ______
Service Fee $______Sum Insured $______

Austbrokers Sydney Pty Ltd

Page 2 of Prospective Foal Insurance Proposal Form

QUESTIONNAIRE
1.   Address where Mare is Kept ______
2.   Have there been any contagious infectious diseases on the premises during the past 12 Mths? If Yes, please provide details Yes [ ] No [ ]
______
3.   Is the mare stabled at night or kept in an enclosed paddock?
Stabled [ ] Paddock [ ]
4.   Has the mare foaled previously? If yes, advise date of last foaling. Yes [ ] No [ ]
______
5. How many previous foals has the mare had ? ______
6. How many previous foals were born dead? ______
7. Has the mare aborted or slipped a foal? If yes, please provide details
Yes [ ] No [ ]
8. Does the mare have any trouble foaling? If yes, give details Yes [ ] No [ ]
______
9. To your knowledge, are there any breeding abnormalities or history of disease or
injury with the mare that might be relevant to her insurance or to the insurance of her
prospective foal? If Yes, give details Yes [ ] No [ ]
______
10. Has any Company or Underwriter at any time ever declined your proposal required
an increased premium, imposed special conditions, cancelled your insurance or
refused renewal of your proposal?, If yes, give details Yes [ ] No [ ]
______

I /We the undersigned hereby propose to insure the prospective foal noted in this proposal subject to the terms and conditions of the Certificate to be issued and I/We declare that the above statements are true and complete and that I/We have not withheld any material information.

Insured Signature: ______Dated ______

Print Name ______

W:\dontlock\ABSRUR\lindam\My Documents\Pros Foal Proposal Form.doc Page 2