For manual submission, download this form here.
DECLARATION OF HEALTH
THIS DOCUMENT MAY AFFECT YOUR RIGHTS UNDER THIS INSURANCE POLICY
PLEASE READ CAREFULLY
I warrant that the horse
DATE OF BIRTH:
COLOUR:
BREED:
SEX:
--------
Stallion
Gelding
Mare
Broodmare
Filly
Colt
IF MARE, IS SHE IN FOAL?
Yes
No
IF YES, DATE BRED:
OWNED BY:
AGENT RESPONSIBLE FOR HORSE:
HEALTH HISTORY: To the best of my knowledge, I warrant that the horse named has been free of any sickness, lameness, illness, injury, physical unsoundness, medical condition, disability, or any condition that could lead to a future claim EXCEPT:
NAME OF REGULAR VETERINARIAN:
VETERINARIAN PHONE NUMBER:
I hereby give my permission for the Insuring Company to contact my Veterinarian and/or Agent responsible for the horse and inquire regarding the health and/or treatment of this horse.
NAME:
POLICY NUMBER:
STREET ADDRESS:
CITY:
PROVINCE:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
POSTAL CODE:
EMAIL:
PHONE NUMBER:
SIGNATURE (ENTER YOUR NAME)
*
:
date signed
D
M
YEAR
