Important
Notice.
Coverage cannot be bound by e-mail, fax or voice
mail. You MUST speak to a licensed broker.
Owner
Information
to
be completed by owner or authorized agent
Full Name
of Registered Owner
If not
sole owner of animal state full details of
designated owners and their interest
Address
Email
Work Phone
Home Phone
Fax
Animal Description
Horse
Name
Breed
Date
of Birth
Sex
Registry
#
Use of
Horse
Date of
Acquisition
Purchase
Price
Purchased
from
Name of
Vet to last
examine this animal prior to the date of this
application
Veterinarian
Address
Postal
Code
Date of
last examination
Reason
for last examination
Name of
regular vet
Distance
from vet by road (in miles)
I saw
this animal personally on (date)
Name
and address of individual who normally cares for
this animal
Are
there any insurance claims in the last 5 years?
If yes,
describe
Have
you ever been refused insurance?
Previous
Insurer
Limits of Insurance
Mortality
The following are available for
an additional premium. Coverage not provided
unless appropriate box marked "YES"
Surgical/Major
medical extension?
If
yes,
Death
Claim expense reimbursement?
Comprehensive
general liability
If
yes,
Twelve
month extension clause?
Special Notice: The amount that
will be paid in the event of a claim will be the
lessor of, the amount shown in the schedule, or
the actual cash value at the time of such claim.
Declaration of Owner
I
will supply CBV with
Vet
Certificate
I
am aware that coverage is NOT in effect until
ALL documentation is received by CBV
Where
did you find us?
please choose from list
another website
word of mouth
I'm an existing customer
phone directory
online directory or search engine
OTHER - please indicate
