Horse Insurance Loss of Use Claim Form

To lodge a Loss of Use claim, simply answer all questions outlined in the form below. Our team will then be in touch shortly to discuss.

Please note: The provision of this form by Coverforce is not an admission of liability or acceptance by Coverforce of your claim. As per page 9 of the Equine Package Policy Wording, the potential loss must result in total and permanent incapacity during the same period of insurance or within 12 calendar months of the date of expiry.

All fields marked with an * are mandatory.

Insured's Details

Full Name *

Contact Number *

Email Address *

Postal Address *

Street address *

City *

State *

Postcode *

Address where the horse was kept *

Street address *

City *

State *

Postcode *

Description of Horse Claimed

Name *

Breed *

Brand & Colour *

Sex *

Date of Birth *

Sum Insured ($) *

General Questions

What date did the horse sustain the injury? *

Where did the horse sustain the injury? *

Cause of illness or injury *

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

Name of Veterinary Surgeon *

Phone Number of Veterinary Surgeon *

Postal Address of Veterinary Surgeon *

Street address *

City *

State *

Postcode *

Additional comments / information

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 *