First Name:

Last Name:

Telephone: (xxx-xxx-xxxx)

Email Address:

Purchase Price:

Insurance Amount:

Breed:

-- Akhal-Teke Andalusian Appaloosa Halter Bloodline Appaloosa Non Halter Bloodline Arabian Donkey Draft Cross Draft Horse Fjord Friesian Friesian Cross Gypsy Horse Cob Half Arabian Icelandic Lipizzan Lusitano Minature Horse Miniature Donkey Missouri Fox Trotter Morgan Saddlebred Mule National Show Horse Paint Halter Bloodline Paint Non Halter Bloodline Paso Fino Peru Paso Pony Quarter Horse Halter Bloodline Quarter Horse Non Halter Bloodline Rocky Mountain Horse Tennessee Walker Thoroughbred Warmblood

Use Of Horse:

-- Showing Pleasure/Hacking Dressage Driving Show Hunter Show Jumper Pony Club Eventing (training) Eventing (preliminary) Field Hunter Endurance/Distance Cutting/Team Penning Reining Roping Barrel Racing Foals Yearlings Breeding Mares Breeding Stallions

Age:

-- Under 30 Days Over 30 Days 1 Yr. 2-14 Yrs.

Major Medical and Surgical Coverage for Ages 2-14. Annual limit up to $7,500, not to exceed horse's insured mortality limit/$300 deductible.
Add $275

Major Medical and Surgical Coverage for Ages 2-14. Annual limit $10,000/$300 deductable.
Add $400

Surgical Only Coverage for Ages 6 months – 17 years - Annual limit $5,000/$0 deductable.
Add $150