Application for Full Mortality Horse Insurance

Complete and submit the online application and mail your cheque, payable to: Colley, Borland & Vale In Trust together with:

1. A dated, signed photo of your horse taken within the last months
2. Bill of Sale
3. Vet Certificate dated within 30 days
4. Copy of registration papers.

(also available pdf application)

Full Mortality Horse Insurance rates and information

Important Notice. Coverage cannot be bound by e-mail, fax or voice mail. You MUST speak to a licensed broker. Owner Information to be completed by owner or authorized agent Full Name of Registered Owner If not sole owner of animal state full details of designated owners and their interest Address Email Work Phone Home Phone Fax Animal Description Horse Name Breed Date of Birth Sex Registry # Use of Horse Date of Acquisition Purchase Price Purchased from Name of Vet to last examine this animal prior to the date of this application Veterinarian Address Postal Code Date of last examination Reason for last examination Name of regular vet Distance from vet by road (in miles) I saw this animal personally on (date) Name and address of individual who normally cares for this animal Are there any insurance claims in the last 5 years? Yes No If yes, describe  Have you ever been refused insurance? Yes No Previous Insurer Limits of Insurance Mortality The following are available for an additional premium. Coverage not provided unless appropriate box marked "YES" Surgical/Major medical extension? Yes If yes,  $2500.00 limit $5000.00 limit $7500.00 limit Death Claim expense reimbursement? Yes ($2,000.00 limit) Comprehensive general liability Yes If yes,  $1,000,000.00 limit $2,000,000.00 limit Twelve month extension clause?  Yes Special Notice: The amount that will be paid in the event of a claim will be the lessor of, the amount shown in the schedule, or the actual cash value at the time of such claim. Declaration of Owner I will supply CBV with   Bill of Sale     Registration  Vet Certificate  Dated Photo   Cheque        I am aware that coverage is NOT in effect until ALL documentation is received by CBV I declare that the animal listed is in good health and physical condition except as stated on the vet's certificate. I warrant the truth of the statements I have made on this application which shall be the base of the Contract for insurance and if anything be falsely stated or information withheld to influence the Company's decision, the Insurance Contract shall be null and void. Where did you find us? please choose from list another website word of mouth I'm an existing customer phone directory online directory or search engine OTHER - please indicate

Full Mortality Horse Insurance information

Underwritten by Equine Insurance Underwriters Limited

106 - 3701 East Hastings Street

Burnaby BC  Canada  V5C 2H6

Phone (604) 293-1531    Fax (604) 293-1248