New York Insurance by Bermack, Champion & Lewine for Auto, Homeowners, Business and Personal Insurance
This website offers services primarily to current and future residents of NY, CT and NJ.
14 Penn Plaza, Suite 1611, New York NY 10122 • Telephone: 212-239-1140
 
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Equine Quote
This Quote is for NY, CT and NJ only
Fill out the form below to obtain a customized equine quote.
To obtain an accurate quote, please be as complete as possible.

Applicant Information

Name:

Street Address:

City/State/Zip:

/ /

Home Phone:

Work Phone:

Email:

Coverage Selections

Desired Effective Date:

Coverage Desired:

 Full Mortality  Surgical  ASD  Loss of Use

 Named Perils Optional Perils

Animal Information

Are any of the animals listed herein financed?  Yes No
If so, state amount, when and to whom due:   
 (Give address)

Is there any other insurance on any of the animals listed herein?

Chiefly kept on premises known as:


(Give complete address of location)

Name and address of trainer:

Animal Information

Name of Animal

Sire

Use

Sex

Purchase Price

Amount Desired

Premium

Breed/Registration #

DvM

 

DOB

Date Purchased

Rate

 

 

Name of Animal

Sire

Use

Sex

Purchase Price

Amount Desired

Premium

Breed/Registration #

DvM

 

DOB

Date Purchased

Rate

 

 

General Questions

If mare in foal, name covering stallion:

Stud fee paid:

If raised foal, stud fee?

Has any animal above named been afflicted with any disease or sickness or received any hurt or injury in the past 12 month period? Yes No  ●  If so, give particulars:

Is any animal named above to be used as a hunter / jumper / eventer or for racing?
Yes No  ●  If so, explain use:

Are eyes, legs, and feet of every animal named above in normal condition? Yes No

Has any animal above ever had colic or indigestion?  Yes No  ●  If so, how often?
When was the last attack?

Give cause of attack, if known: 

How many animals did you lose by death in the past 3 years? Cause of death?
Date of death
   Insured amount paid $   
How many other animals of this type do you own?

Was purchase price cash, trade or both?  Cash   Trade  Both  ●  If any part trade, state what it consisted of, and state what amount cash was paid: 

Thank You!
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