For manual submission, download this form here.

DECLARATION OF HEALTH

THIS DOCUMENT MAY AFFECT YOUR RIGHTS UNDER THIS INSURANCE POLICY
PLEASE READ CAREFULLY

I/We warrant that the horse named

of SEX:

BREED:

SIRE:

DAM:

COLOUR:
MARKING:	DATE OF BIRTH:

is free from any sickness, lameness, illness, injury, medical condition, physical unsoundness (ie: wind and limb), disability, or any condition that could lead to a claim, at the date and time of application for insurance, EXCEPT:

HEALTH HISTORY - PREVIOUS 12 MONTHS ONLY

I/We further warrant that the horse named has been free of any sickness, lameness, illness, injury, medical condition, physical unsoundness, disability, or any condition that could lead to a claim, for the last twelve months, EXCEPT:

I/We understand that the insurance for which I/we are applying DOES NOT COVER ANY PRE-EXISTING MEDICAL CONDITIONS.

Name of Regular Veterinarian:
Veterinarian Phone Number:

I/We hereby give permission for the Insuring Company to contact the Veterinarian and inquire regarding the health and/or treatment of this horse.

Name: (please print)

PHONE NUMBER:

STREET ADDRESS:

CITY:

POSTAL CODE:

PROVINCE:

SIGNATURE (ENTER YOUR NAME)*:		date signed
			D	M	YEAR

DECLARATION OF HEALTH

THIS DOCUMENT MAY AFFECT YOUR RIGHTS UNDER THIS INSURANCE POLICY PLEASE READ CAREFULLY

THIS DOCUMENT MAY AFFECT YOUR RIGHTS UNDER THIS INSURANCE POLICY
PLEASE READ CAREFULLY