Horse Insurance Health Declaration

To complete this health declaration, 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.

Name of Insured *

Policy Number *

Name of Horse *

The horse is: *

Colour *

Breed *

Choose one: *

Filly/MareColt/StallionGelding

Height *

Microchip Number

Date of Birth *

Use(s) of Horse *

To your knowledge, has this horse been administered any medication within the last 45 days? *

YesNo

Please provide details *

Is the horse sound and healthy, free from vice, and well cared for in every aspect? *

YesNo

Please provide details *

During the last 12 months, has the horse had any surgery/veterinary treatment/x-rays given? *

YesNo

Please provide details *

During the last 12 months, has the horse suffered from any illness or injury? *

YesNo

Please provide details *

No Insurance is in force until this Health Declaration has been accepted by the Underwriter.

Veterinary Certificates will be required annually, at your cost, in the following instances (unless advised):

*additional examinations required as detailed below.

Veterinary Certificates are to be returned to Coverforce no later than 14 days after the examination date.

Conditions of Restricted Loss of Use Examinations

Up to $25,000 sum insured:
- Inception & Renewal Requirements: Veterinary Certificate including Flexion and Hoof Tests of all four limbs
$25,001 to $50,000 sum insured:
- Inception Requirements: Veterinary Certificate and X-Rays of all four limbs
- Renewal Requirements: Veterinary Certificate, including Flexion and Hoof test of all four limbs
- If lapse in cover (exceeding 2 weeks) then revert to Inception Requirements to reinstate policy
$50,001 to $100,000 sum insured:
- Inception & Renewal Requirements: Veterinary Certificate and X-Rays of all four limbs

I/We do hereby agree:

the answers contained in this Declaration are in every respect true and correct, and I/We have not withheld any material information likely to effect the acceptance of the Declaration.
to exercise all reasonable precaution for the safety of the horse(s) to be insured.
to accept renewal of the insurance subject to the terms, exclusions, conditions and limitations of the Company's Policy.

Insured's Signature *

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Date *