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Equestrian Quotation Request Form

* Required

Application Contact Information

Prefix:

* First Name:

* Surname:

* Address 1:

Address 2:

* City:

* State / Province:

* Zip / Postal Code:

* Country:

* Citizenship:

* Country of Residence:

* Telephone:

Fax Number:

* E-mail:

 

Horse Information * at least one horse must be entered

How many horses?

1.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

2.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

3.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

4.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

5.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

6.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

7.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

8.)

* Name

* Reg # / Tattoo # * Sex

* Date of Birth

 

* Exact Use

* Breed

* Date Acquired

* Purchase Price

* Amount Insured

$

$

 

Coverage Requested

* Full Mortality & Theft:

$

* Major Medical:

$

Liability:

$

Surgical Only :

$

Accidental Loss :

$

Stallion Infertility :

$

 

Questions

* Does anyone else have a financial interest in any animal?

Yes No
If Yes, then who?

Location of Stable (Stable's Name, Address):

* Are all of the animals healthy and capable of performing intended use?

Yes No
If no, then which horse(s) and what is the problem?

Who is your veternarian? (Name, Address, Telephone)

How long have you used this veternarian?

* Please identify the current insurance provider:

* What are the current insurance coverages and premiums?

Has any insurance provider cancelled or refused to renew coverage?

Yes No
If Yes, then explain:

Has any horse owned by you died in the past three years?

Yes No
If Yes, please explain:

Substantiation of Insurance

* Are you able to provide the following information on all horses?

Performance / Show Records: Yes No
Breeding Records: Yes No
Appraisals: Yes No

   
 
   

PHONE: +1-866-510-0149

International Insurance & Investments LLC

1725 Washington Rd. · Suite 406
Pittsburgh, PA. 15241 USA

International Insurance & Investments LLC is licensed in the European Economic Area, Switzerland, The United Kingdom and the United States of America. In the USA, the firm is licensed in 17 states. In the United Kingdom, the firm is authorized and regulated by the Financial Services Authority # 315054.


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