Horse Insurance Claim Form

To lodge a Horse Insurance Claim, simply fill out the details in the form below. Our team will then be in touch with you shortly to discuss your claim.

Please note: The provision of this form by Coverforce is not an admission of liability or acceptance by Coverforce of your claim.

All fields marked with an * are mandatory.

Insured Details

Full Name of Insured *

Date of Birth *

Are you registered for GST? *

YesNo

ABN Number *

ITC Proportion *

Policy Number *

Contact Number *

Email Address *

Postal Address *

Street address *

City *

State *

Postcode *

Address where the animal was kept *

Street address *

City *

State *

Postcode *

Description of Animal Claimed

Name *

Breed *

Brand & Colour *

Sex *

Date of Birth *

Sum Insured ($) *

Additional Comments

General Questions

Date the vet attended *

Time the vet attended *

Name of veterinary surgeon *

Type of Claim *

Upload a copy of the veterinary report, diagnosis & autopsy *

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Date the animal died or was destroyed *

Time the animal died or was destroyed *

What was the current value of the animal at the time of occurrence and why? *

Date the animal sustained the injury *

Place the animal sustained the injury *

Cause of illness or injury *

Who was in charge of the animal at the time of illness or injury? *

If illness or injury was caused by the apparent negligence of any person, please provide:

Name

Occupation

Address

Street address

City

State

Postcode

Reason for thinking this person caused the illness or injury

Was salvage obtained from the carcass? *

YesNo

Amount ($) *

Please upload a receipt *

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Please provide details of any previous treatment or medication administered to this animal whilst in your possession *

Have you received livestock insurance payments before? *

YesNo

Please provide details *

Was the animal, now the subject of this claim, insured elsewhere? *

YesNo

Has any other person or company shown financial interest in this animal? *

YesNo

Name of interested party *

Address of interested party *

Street address *

City *

State *

Postcode *

What is their interest? *

Have you ever had an insurance claim declined? *

YesNo

Please provide details

Have you ever had an insurance Certificate declined? *

YesNo

Please provide details *

Privacy Consent

I consent to Coverforce:

Collecting and using my personal information for the purposes of administering my claim, including investigating, assessing and paying any claim made by me or on my behalf. (If we do not collect this information we may not be able to process your claim.)
Disclosing my personal information to related entities of Coverforce, the insured (if not myself), other insurers and reinsurers, insurance reference bureaus, law enforcement agencies, investigators, lawyers, assessors, repairers, advisors and the agent of any of these, insurance broker, insurance agent or other intermediary, my employer or Australian Financial Complaints Authority (AFCA) for the purposes of administering my claim or providing a report.
I understand that a copy of the Coverforce privacy policy statement, including information about access, may be obtained via the Coverforce website here or by calling 1300 503 503.

Insured's Signature *

Draw signature|Type signatureClear

Date *