Print and complete the following application and mail with your cheque, payable to:

Colley, Borland & Vale In Trust together with: (also available online application or pdf application)

1. A dated, signed photo of your horse taken within the last 30 days

2. Bill of Sale
3. Vet Certificate dated within 30 days (download pdf) get Acrobat Reader
4. Copy of registration papers.

Coverage NOT in effect until ALL documentation is received.

Broad Form Named Perils Horse Insurance information

Name:
Address:		Postal Code:
Home Telephone:(    )	Business Telephone:(    )
Horse Name:		Breed:
Date of Birth:	Sex:	Registry #:
Location of Horse:	Value:	Premium:
Veterinarian Name:
Veterinarian Address:		Postal Code:
Last Vet Visit:	Reason:
Last Wormed:	Last Shots:
I request optional Vet Coverage         Yes No (Applicable to insured perils only)
Amount Requested: $	Premium:
I have enclosed:
1. Bill of Sale 2. Registration 3. Vet Certificate 4. Dated Photo 5. Cheque

I hereby certify my horse has no pre-existing condition or illness that affects this policy coverage.

Date:                              Signature: