Desired Effective Date:
Perils Optional Perils
Are any of the animals listed herein financed? Yes
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:
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?
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?
Trade Both ● If any part trade, state what it consisted of, and
state what amount cash was paid:
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