(4) Is there any other insurance applying to the horse(s) listed?
If "Yes", an explanation is REQUIRED.
(5) Does anyone else have any interest in the horse(s) listed?
If "Yes", an explanation is REQUIRED.
(6) Has any Insurance Co. cancelled or declined similar insurance?
If "Yes", an explanation is REQUIRED.
(7) Has any of the listed horse(s) has any illness, disease, lameness, injury, accident or physical disability in the past 2 years?
If "Yes", an explanation is REQUIRED.
(8) Has thre been any contagious or infectious disease on your premises during the past year?
If "Yes", an explanation is REQUIRED.
(9) Have any horse(s) in your care of ownership died in the past two years?
If "Yes", an explanation is REQUIRED.
(10) Mare in foal?
to whom?
Stud Fee:
(11) Stallions:
A) Present stud fee:
B) No.booking this season:
C) No. mares services last year:
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*Values other than the purchase price are subject to acceptance by the company. Details of prize winnings, performance, service fees, number bookings and other pertinent information must be submitted for consideration of stated values (use below for Details)
REMARKS/COMMENTS/SHOW RECORD:
NEW JERSEY: Any person who includes any false or misleading information on an application for insurance policy is subject to criminal and civil penalties.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
VIRGINIA: It is a crime to knowingly provide false, incomplete information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fine and denial of insurance benefits.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties.
To the best of my/our knowledge and belief the horse(s) that is/are the subject of this renewal notice is/are now in sound and healthy condition and has/have not required the care of a veterinarian for any illness or injury during the past policy period.
Furthermore, at the present time, the horse(s) is/are not suffering from any type of chronic or acute condition such as Laminitis,
Navicular Disease, Arthritis, Neurological Disorders, Heaves, Emphysema, Bleeding, Tying-Up, Colic, EPM or Intestinal Disorders, or any type of equine malady.
I/We understand and agree that the policy to be issued shall be founded upon the statements contained herein, and this statement shall be the basis of the contract, and if anything be falsely stated or information withheld, the insurance shall be null
and void.
Electronic Signature:
Date:
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