Fillable AMERICAN RELIABLE INSURANCE COMPANY STATEMENT OF HEALTH (Risk Placement Services, Inc.)

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AMERICAN RELIABLE INSURANCE COMPANY STATEMENT OF HEALTH (Risk Placement Services, Inc.)

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A8198M0915
AMERICAN RELIABLE INSURANCE COMPANY
STATEMENT OF HEALTH
APPLICANT INFORMATION
Name _____________________________________________________ E-Mail Address ________________________________________
Mailing Address ____________________________________________ Phone ________________________________________________
City, State, Zip _____________________________________________ Preferred Date for Policy Inception ________________________
Previous Insurance Carrier __________________________________ Amount of Insurance____________________________________
Horse Name
Breed
Birth Date
Color
Sex
Use
1
Is the horse currently sound and healthy for intended use?
2
Horse ancestry known to carry HYPP? (American Quarter, Appaloosa or Paint)
3
Horse been HYPP tested? Test Results: N/N N/H H/H
4
Does the horse have any past or present conformation problems, defects or ailments, illness, or disease, lameness, injury, or
physical disability including but not limited to laminitis/founder, osteochrondritis dissccans (OCD), neurological disorders(e.g.
EPM), navicular disease, and / or degenerative joint disease (DJD)?
Yes No
5
Any previous history of colic, colic surgery, impaction, or intestinal disorder within last 12 months?
6
Has the horse been nerved or received any surgery, treatment, or examination for lameness?
7
Has the horse been treated or examined by a veterinarian for anything other than routine care within the last year?
8
Has the horse undergone diagnostic ultrasounds, X-rays, or bone scans with the past 36 months?
9
Has the horse received any joint injections in the past 12 months? If yes, specify joints injected, dates and reasons for injections
below.
Yes No
10
Has the horse received any type of medication long term or short term, or any preventative treatments in the past 12 months?
11
Does the horse receive any other medications / supplements?
12
Are there any other current or prior health conditions to which the horse has been exposed?
13
Will the horse be outside the continental United States or Canada during the coverage period?
14
(Mares Only) Is the horse due to foal any time during the requested policy period? If yes, please provide:
Expected foal date ________________________; # previous foals __________________; Stud Fee __________________
Yes No
15
(Mares Only) Has horse ever experienced birthing difficulties? If yes, explain below
If “YES” was answered to any question above, please provide details below: (Also provide any additional comments regarding general evaluation of the
named horse and professional opinion on soundness of horse)
I unde
rstand and agree that the policy to be issued shall be founded upon the statements contained herein and / or in the application and
this statement as well as the application and supporting materials shall be the basis of the policy contract and if anything be falsely
stated, or information withheld, to influence the company’s decision, the insurance shall be null and void.
Si
gnature of Applicant of above named animal: Date:
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AMERICAN RELIABLE INSURANCE COMPANY STATEMENT OF HEALTH (Risk Placement Services, Inc.)

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Completed 30 July 2020

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