MortalityInsuranceApplication Printable Form

Peterson Insurance Services

14866 S.E. 25th Ave Summerfield, FL 34491

Phone (352) 347-8478 Fax: (352) 347-3525 1-888-533-8304

Please Print this form by pressing Print from your Web Browser, Completing completely and mailing or faxing to Peterson Insurance Services 14866 S.E. 25th Ave Summerfield, Fl 34491 Phone (352)347-8478 Fax (352) 347-3525

Important: No Application will be considered if not fully completed and signed by the Assured and Veterinarian within 20 days of inception..

Name of Applicant: ________________________________

Social Security # __________________ Coverage Amt:___________

Policy Period:_____to_____ Occupation:_________________

( ) Mortality $_______ ( ) Specified Perils $________ ( ) Other $_______ ( ) Major Medical & Surgical

Address: ______________________________City_____________State_____Zip________

Phone Number:_________________

Instructions:

1. A photograph is required for unregistered animals.

2. Use these codes for sex of animal/s: M=Mare, S=Stallion , F=Filly , C=Colt , G=Gelding.

3. Requests for amount of insurance, if different from purchase price, are subject to Company review.

Horse 1

Name & Registration # ___________________________Purchase Price$__________ Acquired from:____________________ Sex (see codes) ____Date of Birth_________ Exact Use_________________________ Amt Insured__________________ Date Acquired:____________

Horse 2

Horse 3

Horse 4

1. Are you the sole owner? Y N If no, list other owners & addresses_____________________________________________________________

2. How frequently was animal wormed during past year? _____________ Method Used_______________________

3. Vaccination Programs:_________________________________________________

4. Was purchase price paid by cash, trade or both? give Particulars:___________________ Are animals now insured?_______ Previously insured?________ If Yes to Either, what company & Insured Amount_______________________________________________________________

5. Are any animals financed or leased? _______________________________________

6. Has any company cancelled or refused to renew your coverage? ________If Yes, Give company, date and reason given for cancellation:____________________________________________________________

7. Name / Address of Loss Payee:_________________________________________________________________

8. Where animals kept (barn, pasture, other)?_________________________________________________________________

9. Has any horse owned by you died in the past 3 years? Y N If Yes Location: _______________________________________________________________________If Yes also state details _______________________________________________________________________

10. Name & Address of usual trainer & Farm Manager: Name:______________________Address:______________________________________

11. Are you insuring other animals with another company? Y N If Yes How Many ______

12. Are animals healthy and capable of performing intended use?_________ How are they used?______________________________ If no, Describe:________________________________________________________________

13. Name / Address / Telephone of your regular Vet ________________________________________________________________________

14. How long has vet treated animals ? _____________

15. Has animal ever been treated for accident, illness or lameness? Y N If Yes, give date & description of treatment: ________________________________________________________________________

I understand that the Insurance being applied for, if accepted by the Company, will be based on the statements made in this application. If information is withheld or falsely stated, any Insurance issued may be subject to recession or modification as provided by the law of the state in which the application was accepted or policy issued.

Applicant Signature ________________________________________________

Date Signed _______________

Please be sure to print out the VET CERTIFICATION and include with this application. No application will be complete without both this application and A Signed Vet Certification. Please click the link above to print out the VET CERTIFICATION FORM to be given to your VET for your Horse/s Vet Exam.

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SUBSTANTIATION FOR VALUE NO INSURED AT PURCHASE PRICE

RACING RECORD

LIFE EARNINGS Horse#___ $_______________ HOW MANY TIMES HAS RACED THIS YEAR?______ LAST YEAR?_______

BREEDING STALLIONS

STUD FEE THIS YEAR Horse #________ $__________ STUD FEE LAST YEAR Horse #_________$_______________ Mares Serviced This Year Horse # _______________ Last Year Horse# ___________________

BROODMARE RECORD

Horse #___________

Date Last Bred:_______ Total Number of foals:______ Highest Price paid for one foal $_________ Total price of all foals sold $______________ Current Sire & Stud Fee $_________________

Horse #___________

Date Last Bred:_______ Total Number of foals:______ Highest Price paid for one foal $_________ Total price of all foals sold $______________ Current Sire & Stud Fee $_________________

For show horses please provide on a separate paper Show Name, Date , Class , Place , ( include division , size of division ), total earnings.

For Home breds please provide Sire, Service Fee, Dam , Selling Price of Progeny by Sire and by Dam.