Your Name: |
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Farm/Company |
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Phone: |
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Mobile: |
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E-mail Address:
*Required
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Address 1: |
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Address 2: |
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City: |
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State: |
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Zip Code: |
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Name of Horse: |
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Breed: |
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Sire: |
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Dam: |
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Year Foaled: |
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Sex: |
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Use: |
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Purchase Price: |
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Purchase Date: |
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Requested Insurance Amount: |
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Major Medical Amount: |
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Please note that Major Medical coverage is not available on all breeds and uses nor on any horse aged 16 years or above. For horses 16 through 18 Surgical Coverage is available at the same limits. |
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Has the above animal suffered from colic or any other colic related illnesses?
If yes please explain dates and details:
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Has the above animal suffered from any other illness, disease, or undergone surgery?
If yes, provide dates & details:
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Has there been any evidence of contagious or infectious disease at the stable/stud farm where the animal is kept?
If yes, provide dates & details:
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Has the animal been fired, blistered, nerved, operated on, suffered tendon problems or received treatment for lameness at any time, or does the animal have faulty conformation?
If yes, provide dates & details:
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Has the animal made a complete recovery?
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Is the above animal normal in eye wind & action to the best of your knowledge?
If no, provide dates & details:
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How long has this horse been in your care/possession?
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Is horse financed or leased? If yes, name, address, and phone number of owner:
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Have any horses owned by you died in the past three years? If yes, cause of death:
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Submission of application does NOT GUARANTEE COVERAGE and is NOT A BINDER.
Confirmation of any coverage must be confirmed by phone. |
