Equestrian Online Proposal Form

Fields marked * are mandatory

Your Details
*Full Name of Insured
*Address
*Post Code
*Phone
Fax
*Mobile
*Email
*Confirm Email
Horse Details
*Horse Name
Sire
Dam
*Colour
*Sex
MareFillyGeldingStallionColt
*Year of Birth
*Use
*Breed
*Sum Insured
*Insurance Options (Please refer to the Products page for more details)
ElementaryAdvancedGrand PrixSuperior Cover
Additional Cover
Stallion Infertility Clause
*Period of Insurance From (The insurance period should be a minimum of 12 months)
*To
*Payment Method
Credit Card (A charge of 2.5% will apply)
Cheque (Please send including the name of your alpaca on the reverse of the cheque)
Monthly payments available for premiums over $500 (We will email a funding agreement within the next 24 hours)
Direct Credit
Insurance History

Has any insurer ever:
*declined your proposal for any insurance, or declined any claim made by you?
YesNo
*cancelled your insurance?
YesNo
*refused you renewal of any insurance policy?
YesNo
*imposed special conditions on any insurance held by you?
YesNo
*Have you ever claimed under any bloodstock/livestock insurance policy?
YesNo
*Are there any other parties (other than the named Insured on this proposal) involved in the ownership of the horse(s) to be insured? Or, are any of the horse(s) proposed for this insurance subject to a lease agreement?
YesNo
If you have answered YES to any of the above questions, please provide full details
*Are the above horse(s) at present normal in eye, wind and action to the best of your knowledge?
YesNo
If No give details
*Have any of the above horse(s) suffered from colic or any other related illness at any time to the best of your knowledge?
YesNo
If Yes give details
*Have any of the above horse(s) suffered from any illness, injury, disease or undergone any surgery at any time to the best of your knowledge? Do they have any blemishes?
YesNo
If Yes give details
*Has there been any evidence of contagious or infectious disease during the past twelve months at the location(s) where the animal(s) are kept?
YesNo
If Yes give details
*Have any of the above horse(s) been fired, blistered, nerved or received treatment for lameness (other than sore shins) at any time to the best of your knowledge or do any of the animal(s) have faulty conformation?
YesNo
If Yes give details
Purchase price of above horse(s)
Purchase date of above horse(s)
If homebred, please advise if stud fee was paid and amount?
*If any of the above are mares, are any currently pregnant?
YesNo
If Yes, what was the last date of mating?
And the expected date of birth
view policy wording online
*I would like to receive the policy documents and invoice via email
YesNo
Click here to read the duty of disclosure
* I have read and understood my duty of disclosure

All information given in support of this proposal, whether oral or written is true and correct. I/We have disclosed to the underwriters all material facts required by law. If accepted, this proposal shall be the basis of the contract and incorporated in the Insurance Certificate. Underwriters reserve the right to place exclusions/warranties on any insurance issued on this application. Note: Any insurance certificate issued on this application will not cover any pre existing conditions of the animal(s) to be insured.

* I have read and agree to the terms and conditions