Equine Mortality Insurance Application

EQUINE MORTALITY INSURANCE APPLICATION

BARN DETAILS

Note: The answer to every question must be full and correct, and every blank must be filled. Please use block letters.

1. BARN CONACT:

1)Named of Barn: ______

2)Address: ______City:______State:______Zip Code:______

3)Home Phone:______Business Phone: ______Email:______

4)Contact ______

1. VETERINARIAN INFO:

1)Named of Veterinarian ______

2)Address: ______City:______State:______Zip Code:______

3)Home Phone:______Business Phone: ______Email:______

4)Named of Performance Veterinarian ______

5)Address: ______City:______State:______Zip Code:______

6)Home Phone:______Business Phone: ______Email:______

1. BARN DETAILS:

1) How many years has the barn been in business? _____

2) Number of employees: Full time _____ Part time _____

3) Number of show horses currently boarded? ______

4) Number of stalls? ______

5) Are show horses individually stalled? ___ No ___ Yes If no, please provide details on how many show horses per paddock.

______

______

6) Name of trainer(s): ______

7) Name and location of farrier: ______

8) Does the barn have a sprinkler system? ___ No ___ Yes

9) Are lightning rods installed on horse facilities? ___ No ___ Yes

10) Has there been any contagious or infectious disease at the farm where the animals are kept?___ No ___ Yes If yes, please provide details.

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11) Have any insured horses been stolen from this facility? ___ No ___ Yes If yes, please provide details.

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12) Have any insured horses died in the last two years? ___ No ___ Yes If yes, please provide details

______

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13)Please complete the chart below for the Applicant’s current General Liability Policy.

Carrier # / Limit / Policy Period / Premium

I/We, the undersigned, hereby apply to insure the scheduled horse(s), subject to the terms and conditions of the Policy to be issued, and I/we declare to the best of my knowledge and belief that the above statements are true and complete and that I/we have not withheld any material information.

I/We understand that immediate notice must be given to the Company upon any injury, illness, operation, disease, or death of an insured horse. Signing this form does not bind the applicant to complete the insurance, but it is agreed that this form shall be the basis of the contract should a policy be issued, and if anything be falsely stated or information withheld to influence the Company’s decision, the insurance contract will be null and void.

Barn Owner Signature ______Date ______

NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED AND SIGNED WITHIN 30 DAYS OF POLICY EFFECTIVE DATE.

EQUINE MORTALITY INSURANCE APPLICATION

EQUINE DETAILS

Note: The answer to every question must be full and correct, and every blank must be filled. Please use block letters.

1. APPLICANT(S):

1)Name of Insured: ______

2)Address: ______City:______State:______Zip Code:______

3)Home Phone:______Business Phone: ______Email:______

4)Occupation: ______

1. HORSE(S) TO BE INSURED (If more than one horse attach schedule):

Name & Registration # / Breed / Birth Date / Color / Sex / Use / Date Purchased / Purchase Price / Amt of Insurance 

 If amount of insurance does not equal purchase price (within last 12 months)/stud fee, attach full details including Justification of Value for each horse.

1)a) Was purchase price  cash,  check,  trade,  other: ______

b)If trade/other, provide full details including a copy of the Bill of Sale/Receipt: ______

F.REQUESTED COVERAGE:

COVERAGE / LIMIT
MORTALITY (Provide requested limit)
MAJOR MEDICAL (Optional- select limit desired) / INCLUDED / $______
YES NO  /  $10,000 $15,000
LIFE SAVING SURGICAL (Optional) / YES NO  / $10,000
COLIC ENDORSEMENT / INCLUDED IF NO MAJOR MEDICAL / $3,000
COLIC ENDORSEMENT / INCLUDED AT NO ADDITIONAL CHARGE
TWELVE MONTH EXTENSION / INCLUDED AT NO ADDITIONAL CHARGE
AGREED VALUE / INCLUDED AT NO ADDITIONAL CHARGE * Subject to requirements

1. OWNERSHIP:

1)Are you the sole owner of the horse(s)?  Yes  No If no, other Owner’s Name & Address: ______

1) Percentage of your ownership: ______%

2) Total value of horse(s): ______(USD)

3) Value of other ownership insured interest: ______(USD)

2)Are there any lienholdersor mortgages on this horse(s)?  Yes  No If yes, please attach details

3)Is this horse(s) being leased? Yes  No If yes, please attach lease agreement.

1. GENERAL:

1)Is the Horse(s) currently insured or has it been insured previously? Yes  No If yes, please attach details including the name of Insurer(s).

2)Have you had any loss in last five years? Yes  No If yes, please attach details of loss,age of horse(s) and whether insured or uninsured.

3)Has any insurer ever declined or refused to renew your equine insurance?  Yes  No If yes, please attach details and reason why.

4)Are there any circumstances within your knowledge or opinion not already disclosed affecting or likely to affect the proposed Insurance?  Yes  No If yes, please attachexplanation of circumstances

DECLARATION OF HEALTH (IF MORE THAN ONE HORSE, ATTACH MULTIPLE COPIES)

TO BE COMPLETED AND SIGNED BY THE OWNER OR PERSON RESPONSIBLE FOR THE HORSE

Please answer the following questions to the best of your knowledge and ability by ticking the appropriate box, if you

need more space to answer, please use the back of this form.

1)Has the horse to your knowledge ever suffered from any form of colic,ulcers or other intestinal or digestive disorder?

If YES give details including recovery status:______YES NO

2)Has the horse to your knowledge undergone any surgical procedure (including castration if within the last twelve months)?

If YES give details including recovery status: ______YES NO

3)Has thehorse to your knowledge ever suffered from any lameness, degenerative join disease/arthritis, navicular disease, fractures, tendon or ligament injury?

If YES give details including recovery status: ______YES NO

4)Has the horse to your knowledge ever suffered from melanomas, sarcoids, warts or any other type of growth?

If YES give details including current status: ______YES NO

5)Has the horse to your knowledge ever had any other accident-injury, illness or disease other than those mentioned in

Questions1, 2, 3 or 4 above?

If YES give details including current status: ______YES NO

6)Has there to your knowledge been any evidence of contagious or infectious disease during the past twelve months in the location

where the horse is kept?

If YES give details including recovery status: ______YES NO

7)During the last twelve months has the horse received attention from any Veterinarian, Physiotherapist, Chiropractor,

Acupuncturist or Homeopathist for any reason other than routine vaccination or obstetric work, or received any other form of treatment

for remedial purposes including farriery. Has the horse received steroidal, non-steroidal, anti-inflammatory or analgesic medication?

If YES give details including recovery status: ______YES NO

8)American Quarter / Paint / Appaloosa Horse: Does the horse have pedigree link to HYPP: YES NO N/A

9)To the best of your knowledge is the horse at present normal in conformation, eyes, heart, wind and action and in good health

and does it therefore in your opinion represent a normal risk for the proposed insurance?

If NO give details: ______YES NO

10)Does the horse have any stable vice(s) and/or behaviors?YES NO

If yes, give details: ______

11)a. Is the horse on inoculation and worming program supervised by vet?YES NO

If no, provide details: ______

1. Has the horse been vaccinated against West Nile? YES NO

12)Has the horse received joint injections? If so, how often, administered by whom and for what reason? YES NO

______

13)Is the horse in competition? If yes, how many times a year? List classes/divisions: YES NO

______

Fraud Warning and Application Signature

FRAUD WARNING:

Any person who with intent to defraud submits an application or files a claim containing false, incomplete or deceptivefacts or

Statementis guilty of insurance fraud, which may be subject to denial of insurance benefits, civil damages,restitution, fines or

confinement in prison, or any combination thereof depending upon the applicable state laws.

I hereby certify that to the best of my knowledge and belief the above particulars are true and correct and that no information

which could materially affect this insurance has been knowingly withheld.

APPLICATANT SIGNATURE______(*Owner/Other -please specify below) DATE ______

NAME (please print) ______

PRODUCING AGENT SIGNATURE______DATE ______

NAME (please print) ______

Lloyd’s Equine Application Form

Usual cover is against the risks of mortality, subject to various conditions, limitations and exclusions. A copy of the wording showing the full extent of the cover may be seen upon application to your broker.

ALL THE QUESTIONS IN THIS APPLICATION FORM ARE RELEVANT TO THE UNDERWRITERS IN PROVIDING THIS INSURANCE AND SETTING THE TERMS AND THE PREMIUM. YOU MUST TAKE CARE IN ANSWERING THE QUESTIONS TO PROVIDE ACCURATE AND COMPLETE INFORMATION. FAILURE TO PROVIDE INFORMATION OR THE PROVISION OF INCOMPLETE OR INACCURATE INFORMATION MAY RESULT IN THE LOSS OF COVER OR REVISED TERMS AND/OR PREMIUM OR IT MAY AFFECT ANY CLAIM YOU MAKE UNDER THIS INSURANCE.

DECLARATION
The above named horses are owned by me and I declare that the information disclosed on this proposal is, to the best of my knowledge and belief, both accurate and complete. I have taken care not to make any misrepresentation in the disclosure of this information and understand that all information provided is relevant to the acceptance and assessment of this insurance, the terms on which it is accepted, and the premium charged. Any change to the information I have provided in this proposal must be notified to the Underwriters.

LLOYD’S EQUINE INSURANCE VETERINARY CERTIFICATE OF HEALTH

(For horses over 45 days of age and valued at greater than $99,999)

The HORSE being examined should be moved outside of the stall to demonstrate soundness of limb and freedom of movement. Careful observation should be made as to housing conditions and the presence of contagious or infectious diseases or other issues relevant to the health/wellbeing of the HORSE.Please use the back of this page to expand on anything in either Section 1 or 2 belowor any other issuethat you feel are relevant to the health or environment of the HORSE.

VETERINARIAN ______Address ______

Licensed to practice in______

Name of Practice ______Telephone ______

Owner/INSURED ______at (Barn) ______

Name of HORSE ______Sex ______Age ______Color ______

Breed ______Use ______Sire ______Dam ______Lip Tattoo No. ______

Instructions to Examining VETERINARIAN completing this form. Please read the following Declarations in Section 1 before completing Section 2. Your signature on this Certificate constitutes your agreement with these Declarations.

Section 1

1. The pulse and respiration are normal.

/ 15.If female, no external symptoms detrimental to normal breeding.

1. The temperature is normal.
2. The eyes are clinically normal.

/ 16.No history or evidence of lameness.
17.No history or evidence of firing or blistering.

1. The heart was auscultated and found normal.
2. No history or evidence of being a bleeder while racing.

/ 18.The stabling is adequate.

1. No history or evidence of nerving.
2. No history or evidence of laminitis.

/ 19.There is no contagious or infectious disease on premises or neighbourhood.

1. No surgery has ever been performed.

/ 20.If foal, birth was normal with no complications.

1. No digestive disorder past or present.
2. No previous history of colic.

/ 21.HORSE has received no medication in past year other than routine.

1. HORSE appears in good health.
2. No indication of infection or disease.
3. If male, HORSE is not believed to be cryptorchid.

/ 22.No conformational abnormalities that would interfere with the HORSE'S intended use or could lead to life threatening problems.

1. If male, both testicles evident and palpate normally

/ 23. No early signs or indications of ataxia.

I declare (to the best of my professional knowledge) that the Declarations listed above are correct in respect of the subject HORSE with the exception of those listed below (please give full details):

Statement # / Details

Section 2

1. Date of Coggins test.

1. Please list diseases currently inoculated against.

1. If female, is she reported in foal?

1. If so, what is her last breeding date?

1. What was the last worming date of the HORSE?

1. Are you the usual VETERINARIAN for the HORSE?

Except as noted above, I certify that to the best of my knowledge and belief this HORSE is healthy and sound and in my opinion is a suitable candidate for mortality insurance for the use stated above.

Date and time of examination: ______VETERINARIAN ______

Signature

NMA2934 For use in conjunction with L.E.(U.S.A.) form

Page 1 of 6 Equine - Rev 09.13.2016