Henry Equestrian Insurance Brokers
download printable version For manual submission, download this form here.
 

APPLICATION FOR HORSE MORTALITY INSURANCE FOR
THRIFTY HEP
TO BE COMPLETED AND SIGNED BY THE INSURED. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
NAME OF OWNER(S)*:
STREET ADDRESS*:
CITY*:
POSTAL CODE*:
PROVINCE*:
BUSINESS PHONE NUMBER:
HOME PHONE NUMBER*:
FAX:
EMAIL ADDRESS *:
DO YOU WANT THIS INSURANCE TO BE ADDED TO AN EXISTING POLICY?          
If Yes, enter policy number:
IS THE HORSE BEING LEASED?    
If Yes, enter lessee name and address:

HORSE DETAILS
HORSE NAME: SEX:   
NOTE:
If this horse is a stallion, are you planning to geld this horse?    
If yes, specify date of operation:
If this horse is a broodmare, indicate date confirmed in foal:
BREED:                      SIRE:    
DAM:
COLOUR:
MARKING:
DATE OF BIRTH
ACQUISITION DATE
ACQUIRED FROM:
TYPE OF SALE:
PURCHASE PRICE OR STUD FEE (if homebred): (A) $
ADDITIONAL EXPENSES RELATED TO PURCHASE*: (B) $
AMOUNT OF INSURANCE DESIRED (A PLUS B): (A + B) $
      *Examples of “Additional Expenses” include but are not restricted to veterinary pre-purchase examination, transportation, quarantine, GST.
1. ARE YOU THE HORSE'S SOLE OWNER?           If No, please explain:    
     IS THERE ANY INDEBTEDNESS?           If Yes, please explain:    
2. DID ANY HORSE OWNED BY YOU OR IN YOUR CASE, CUSTODY AND CONTROL DIE IN THE PAST 36 MONTHS?        
     If Yes, state cause of death:
     Were any insured?           Give particulars:      
3. HAS ANY INSURANCE COMPANY EVER CANCELLED ANY INSURANCE OR REFUSED TO INSURE ANY ANIMAL(S) IN WHICH YOU HAVE OR HAD
     AN INSURABLE INTEREST?           If Yes, give particulars:    
4. STATE NATURE OF ANY ILLNESS OR INJURY TO THE ABOVE HORSE IN THE LAST 36 MONTHS:    
5. WAS THIS HORSE PREVIOUSLY INSURED BY YOU OR ANY OF ITS OWNERS APPLYING FOR INSURANCE?        
     If yes, indicate when, expiration date, for what amount, company name and policy number:    
6. HOW OFTEN WAS THE HORSE WORMED IN THE LAST 12 MONTHS?           METHOD OF WORMING:    
     LAST WORMING DATE:
7. LOCATION OF ANIMAL:
     PHONE NUMBER:       PERSON IN CHARGE:    
8. WHAT IS THE HORSE'S INTENDED USE?
9. HAS THIS HORSE BEEN VACCINATED AGAINST THE WEST NILE VIRUS?        
     If Yes, please provide the date of vaccination, veterinarian and schedule:    
   *If No, please be aware any claim due to the West Nile Virus will be denied unless proof of inoculation is provided.
10. LIST OTHER CURRENT VACCINATIONS ADMINISTERED AND THE NAME OF YOUR REGULAR VETERINARIAN:
11. IS THE ABOVE ANIMAL ON REGULAR MEDICATION?               If Yes, explain:

WHAT WILL IT COST?

THE "THRIFTY" HEP PLAN – 2% of the insured value
 

What is Included At No Additional Cost:

  • $1,000 Death Claim Veterinarian Reimbursement
  • $1,000 Tack and Equipment
  • $1,000,000 Personal Liability
 
COVERAGE INSTRUCTIONS   LIMIT OF INSURANCE      YES          NO   PREMIUM
Mortality Insurance $ x 2.0% (min. $100/horse) $

Emergency Only Veterinarian Expenses $     $
$75 per each $1,000 coverage – Maximum $5,000

Increased Tack and Equipment $     $
$20 per each additional $1,000 of coverage - Maximum $5,000

INCREASED PERSONAL LIABILITY$ 2,000,000     $

Sub-Total
Ontario residents add RST 8%
Total

Method of Payment

  1. 1 cheque made payable to Henry Equestrian Insurance Brokers ltd.;
  2. 3 post-dated cheques over 3 consecutive months;
  3. 1 VISA or MasterCard payment;
  4. 3 post-dated VISA or MasterCard payments over 3 consecutive months;
  5. A monthly payment plan (offered to clients with a premium of $500 or over);
  6. On-line banking.

I-We understand and agree that the policy to be issued shall be founded upon the statements contained herein; that animals having heaves or vicious habits, that animals which are colickers or emphysematous or bleeders or blind or nerved at or above the fetlock or orphan foals under 90 days of age are not insurable; that the company shall not be liable for any loss caused by an insured animal becoming unfit or incapable of fulfilling the functions, use or duties for which it is kept, used or intended, unless the ‘Disability’ endorsement is applied to the policy; and that no operation be performed on any insured animal without the WRITTEN consent of the company unless the operation is necessary, as a result of a peril insured by the policy.

I-We understand and agree that immediate notice and full details of any lameness, illness, injury or death of the animal will be given to the insuring company. I-We agree that this application shall be the basis of the contract and if anything be falsely stated or information withheld to influence the company’s decision, the insurance contract shall be null and void. It is understood, however, that the signing and filing of this application does not bind the company and no insurance shall be deemed effective unless and until this application is received and accepted by the company and any binder of coverage shall then be effective only upon receipt by the insurance company.
SIGNATURE (ENTER YOUR NAME)*: date signed
D M YEAR