Horse Insurance Application Form

To complete this Horse Insurance application, simply answer all questions outlined in the form below. Our team will then be in touch shortly to discuss.

All fields marked with an * are mandatory.

Full Name *

Phone *

Email Address *

ABN

Are you registered for GST? *

YesNo

Address *

Street address *

City *

State *

Postcode *

Sections 1, 2 & 3: Mortality, Theft/Straying & Loss of Entry Fees

Our Horse Insurance Package is underwritten by Certain Underwriters at Lloyd's.

Section 1: Mortality

From $1,000 up to and including $100,000 (limited to $5,000 for horses 16 years and over)
Cover for death, or euthanasia on humane grounds, resulting from accidental injury, illness or disease
Includes up to $200 for an Autopsy report following a claim
Covers horses from 24 hours old up to and including 20 years of age
Covers whilst your horse is being transported within Australia and while temporarily in New Zealand, including any journeys between these areas
An excess of $nil to each claim

Section 2: Theft & Straying

Theft or straying where the horse is not recovered within 90 days, plus up to $300 for advertising and reward.

Section 3: Entry Fees

Loss of irrevocable entry fees up to $300 following a claim under Section 1 - Mortality.

Cover Commencement Date *This is an annual policy providing 12 months of cover from the Commencement Date.

Sum Insured *Should the Sum Insured be greater than the Purchase Price, please attach detailed justification in the field below.

Date of Purchase *

Purchase Price ($) *

Please provide further details

Description of the Horse to be Insured

Horse Name *

Sex *

Colour *

Height *

Date of Birth *

Sire *

Dam *

Breed *

Microchip Number

Registration Number

Association/Society

Primary Address of Horse *

Street address *

City *

State *

Postcode *

Please specify *

Horse Brandings and/or Markings (please attach photographs below) *

Image 1

Browse

Image 2

Browse

Image 3

Browse

Image 4

Browse

Image 5

Browse

Image 6

Browse

Horse Health / Care

Does a farrier regularly attend to the horse? *

YesNo

Frequency *

Any corrective shoeing? *

How often is the horse under supervision? *

ConstantDailyWeekly

Does the horse suffer from any congenital and/or conformation fault? *

YesNo

Please specify *

Has the horse suffered from or been treated for any injury, illness or disease? *

YesNo

Please specify *

Has any industry professional advised that items outlines in question 3 and 4 may predispose the horse to future injury, illness or disease? *

YesNo

Please specify *

Please provide the following details of your regular Veterinary Surgeon (we may contact them for further information).

Veterinary Name *

Veterinary Phone Number *

Veterinary Address *

Street address *

City *

State *

Postcode *

If the horse is leased, please provide the owner's details (we may contact them for further information).

Owner's Name

Owner's Phone Number

Owner's Address

Street address

City

State

Postcode

Is there any other party with financial interest in the horse(s) proposed for insurance e.g. Syndicate/Other Owners?

YesNo

Is Insurance required for that party's interest? *

YesNo

General

Has any Insurance Company declined an Application from you, cancelled or refused to renew your certificate or required special terms to insure you? *

YesNo

Please provide full details *

Have you made a horse insurance claim in the past 5 years? *

YesNo

Please state details of the losses *

Optional Extensions

Section 4 - Public Liability (also available as a stand-alone cover)

Cover for your legal liability in respect of accidental:
- death, bodily injury, illness, or disease of any person;
- loss of, or damage to, tangible property arising from your ownership and use of the insured horse
Includes legal costs
An excess of $250 to each property damage claim

I would like to add this extension *

YesNo

Please select an option *

$1,000,000$5,000,000$10,000,000

Section 5: Loss of Use

Restricted – Cover in the event of an injury, illness or disease that that results in the horse becoming totally and permanently incapable of fulfilling its principle use as stated. Horses aged 2 up to and including 20 years of age when cover commences.

Breeding – Cover in the event of injury or illness that renders the Stallion/Colt totally and permanently impotent, infertile or incapable of natural service. Horses aged 2 up to and including 15 years of age when cover commences.

An excess of $nil to each Loss of Use claim

I would like to add this extension *

YesNo

Please select a 'loss of use' option *

RestrictedBreeding

Section 6: Life Saving Surgery & Snake Bite Veterinary Fees

Reasonable veterinary fees for general anaesthetic surgical procedures performed to save the life of a Horse subject to the maximum limit of $5,000 during the Period of Insurance (or as specified in the Certificate). A $2,000 sub limit applies for veterinary treatment to save a Horse as a result of a diagnosed snake bite.

An excess of $500 for any individual Life Saving Surgery or Snake Bite Claim

I would like to add this extension *

YesNo

Section 7: Saddlery & Tack

Loss or damage to your riding equipment up to the value of $20,000
No article will be deemed of greater value than $500 unless specified on the certificate
An excess of $50 applies to each claim

I would like to add this extension *

YesNo

Description of Nominated Items

Sum Insured ($)

Total Sum Insured ($)

Section 8: Personal Accident & Dental

$5,000 for death, permanent disability, loss of sight or limb
$2,500 for death if the deceased is under 18 years of age
$750 for dental treatment
An excess of $nil to each claim

I would like to add this extension *

YesNo

Your Duty of Disclosure

Your Duty of Disclosure (If you are not a consumer):

Before you enter into an insurance contract, which is not a consumer insurance contract (as that term is defined in the Insurance Contracts Act 1984 or ICA), you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. You have this duty until the insurer agrees to insure you. You have the same duty before you renew, extend, vary, or reinstate an insurance contract. You do not need to tell the insurer anything that:

reduces the risk they insure you for; or
is common knowledge; or
the insurer knows, or should know; or
the insurer waives your duty to tell them about.

If you do not tell the insurer anything you are required to, they may cancel your contract, or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed.

Duty to not make a misrepresentation (if you are a consumer)

There are specific duties that apply to you when you enter into, vary or extend a consumer insurance contract - which is defined in the ICA as one obtained wholly or predominantly for your personal, domestic or household purposes e.g., domestic car, house, travel or accident & illness insurance.

You have a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to the insurer (your duty). Your duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA. Your duty applies before you enter into the policy, and also before you renew, extend, vary, or reinstate the policy. Before you do any of these things, you may be required to answer questions and the insurer will use the answers you provide in deciding whether to insure you, and anyone else to be insured under the policy, and on what terms. To ensure you meet your duty, your answers to the questions must be truthful, accurate and complete. If you fail to meet your duty, the insurer may be able to cancel your contract, or reduce the amount it will pay if you make a claim, or both. If your failure is fraudulent, the insurer may be able to refuse to pay a claim and treat the contract as if it never existed.

Fraudulent Claims Clause (Australia)

If any claim made is in any respect fraudulent or if any fraudulent means or devices are used by You or anyone acting on the Your behalf to obtain any benefit under this Policy, or if any loss under the terms of this Policy be brought about by the wilful act or with the collusion of You, We without prejudice to any other right(s) we might have under this Policy, may be entitled to refuse to pay such claim.

What you do not need to tell us

You do not need to tell Us about any matter:

that diminishes Our risk;
that is of common knowledge;
that We know or should know as an insurer; or
that We tell You We do not need to know.

Who does the duty apply to?

The Duty of Disclosure applies to You and everyone that is an insured under the Policy. If You provide information for another insured, it is as if they provided it to Us.

What happens if the Duty of Disclosure is not complied with?

If the duty of disclosure is not complied with We may cancel the Policy and/or reduce the amount We pay if You make a claim. If fraud is involved, We may treat the Policy as if it never existed, and pay nothing.

Electronic Delivery of Documentation

To save you time and paper and improve our services we will be providing all documents electronically (including insurance policies, Product Disclosure Statements, Financial Services Guide and other disclosure documents) by email with PDF attachments to the email address provided.

If you do not wish for us to communicate with you in this way or no longer wish to receive documentation from us electronically or you require a hard copy of any documentation, please contact us on 1300 503 503 or email horse@coverforce.com.au.

Declaration of Health & Facts

I/We hereby acknowledge that my/our duty of disclosure has been brought to my/our notice as per the disclosure notice printed with this Application Form.
I/We declare that the Horse proposed for this insurance is in good health and is free from injury, disability, abnormality or illness and has been so for the past twelve (12) months and that I/We have answered all questions truthfully and accurately and not withheld any information likely to affect acceptance of this Application.
I/We are aware that my/our answers to the above questions will be subjected to acceptance and may lead to variations in cover, exclusions being applied or entire declination of cover for my/our horse.• I/We hereby acknowledge that no insurance is in force until this Application Form and any Veterinary Certificate/s (if required) have been accepted by Coverforce.• I/We also declare that the information provided in this Application Form by me/us is correct in every particular.

Insured's Signature *

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Date *

General Advice Warning

This document has been prepared without taking into account your objectives, financial situation or needs. You must therefore assess whether it is appropriate, in the light of your own individual circumstances, to act upon this advice.Please refer to the Insurance Product Disclosure Statement (PDS) prior to making any decision to acquire that product.