Contact Information

Name:

Street Address:

City:

State:

Zip Code:

Telephone:

Fax:

E-mail Address:

How would you like us to respond? (Select One):

E-mail Phone Fax

How did you learn about Us?:

Horse Information

Breed:

Age (based on January 1 of this year as birthrate):

Gender:

Value you'd like to insure for:

Please note that the insured value you request may need to be substantiated to the underwriters by purchase price, competition record, or breeding record.

Use (Select all that apply):

Breeding

Cutting

Dressage

Foal/Weaning/Yearling

Racing

Eventing

Hunter

Halter

Jumper

Pleasure (no jumping)

Reining

Roping

Show (no jumping)

Team Penning

Other

If you selected Other, please put use here:

If you selected Show (no jumping), please indicate type of showing here:

Major Medical and Surgical Coverage's

Select just one of the following four:

Major Medical/Surgical (up to $5,000 limit)

Major Medical/Surgical (up to $7,500 limit)

Major Medical/Surgical

 ($10,000 regardless of Mortality value)

Surgical Only

Additional Coverage's

Loss of Use - Accident Only:

International Coverage (for outside continental U.S. and Canada):

If you need international coverage, please indicate what countries the horse will be located in, and during what time period:

Please indicate here any health problems (injury, illness, accident, or disease) the horse has experienced in the last 24 months. Please note the problem, when it started, the treatment, and resolution. Please note: The underwriters may apply an exclusion to the policy for any existing or pre-existing health conditions.

Important: While we will be happy to provide you with an initial quote based on the information above, the quote is not a guarantee of coverage. Also, the quotation process is not a binder. If you would like to bind coverage on your horse, you must speak directly to an agent and provide the required documentation for review.