^{Animals being examined for insurance should be moved about outside to demonstrate soundness of limb and freedom of movement. Careful observation and inquiry should be made as to housing conditions and the presence of contagious disease. This Certificate should be completed by the examining, licensed veterinarian to the best of his/her ability. Completed certificates should be forwarded immediately to the above address.}

^{I___________________________________ do hereby certify that I am a graduate veterinarian holding a current license as such to}

^{Practice in the state of_______________________________ and that I have this day examined:}

^{1.NAME_________________________________AGE_________COLOR_____________SEX______BREED________________}

^{SIRE________________________________________ DAM________________________________________________________}

^{OWNED BY_________________________________________ADDRESS_____________________________________________}

^{Any pulse or respiration problem ? Y(  ) N(  ) Any Eye problems? Y(  ) N(  )}

^{Is temperature normal? Y(  )N (  ) Any heart problem? Y(  ) N(  )}

^{Any history or evidence of bleeder? Y(  ) N(  ) History or evidence of nerving? Y(  )N (  )}

^{Has horse been fired or blistered? Y(  ) N(  ) Any other operation performed Y (  )N (  )}

^{History of Colic? Y(  ) N(  ) History of laminitis/Founder? Y(  ) N(  )}

^{If mare, is she reported in foal? Y (   ) N(   ) Has animal been castrated? Y(   )N (   )}

^{If male, are both testicles evident? Y (   )N (  ) Vices or objectionable habits? Y (   ) N(   )}

^{Date last wormed____________________________________ How often wormed_______________________________}

^{If any surgery has been preformed, has animal fully recovered?________________________________________________}

^{Is there any likelihood of future danger to life or limb as a result of such surgery?__________________________________}

^{Any lameness or faulty confirmation or other abnormal condition?_____________________________________________}

^{In your opinion or to your knowledge are there any medical facts that should be brought to the attention of the Insurance Company?___________________________________________________________________________________________}

^{Any indications of contagious disease on premises or in area?__________________________________________________}

^{EXCEPT AS NOTED ABOVE, I HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE  & BELIEF THIS ANIMAL IS SOUND.}

^{Remarks______________________________________________________________________________________________}

^{Signed_______________________________ Date of_____________,20__ Examiner_________________________________}

^{Printed Name:__________________________}

^{Address_________________________________________________Phone___________________ DVM # ______________}

^{I have this day performed a manual examination on the mare listed above, and I have followed customary standard veterinary clinical procedures in performing this examination. Based upon my findings from this examination it is my opinion:}

^{______1. That said mare is in foal; and}

^{______2. That said mare is not carrying twins, but this cannot be determined with absolute certainty by my examination.}

^{______3. That said mare is barren.}

^{______4. That said mare is clean and sound for breeding}

^{Date (s) ultrasound performed_________________________________________________________________________}

^{Remarks__________________________________________________________________________________________}

^{Signed______________________________ Date_________________}