SOH-Albracht Insurance Agency LLP "*" indicates required fields STATEMENT OF HEALTHThis Statement of Health can only be completed on animals 31 days old to 15 years. Foals under 31 days old, must have a foal examination form by a veterinarian. All animals over 15 years, need to have a veterinary examination form. All animals over $100,000, must be examined by a veterinarian.Name of HorseHow long have you owned horse?Name of Insured First Last Age / Breed / Sex / UseMailing Address Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* If female, is she in foal? Yes No Estimated Foaling Date:Has the horse been castrated? Yes No If male, are both testicles visible? Yes No If any of the following are answered "NO," please explain.Pulse/respiration normal? Yes No Temperature normal? Yes No Is stabling adequate? Yes No ExplanationIs the horse currently free of lameness and healthy, without the use of drugs, for the use intended? Yes No If any of the following are answered "YES," please explain.Does the horse have any past conformational problems or defects, illness or disease, lameness, injury or physical disability including but not limited to: laminitis/founder, OCD, neurological disorders e.g. EPM, navicular disease and/or degenerative joint disease? Yes No Has the animal suffered any illness or injury in the last 12 months? Yes No Has the horse had any colic, impaction, colic surgery or intestinal disorders within the last 36 months? Yes No Has the horse been nerved or received any surgical treatment for lameness? Yes No Has any type of surgery been performed? Yes No Has the horse undergone diagnostic ultrasound, bone scan, or x-rays within the last 36 months? Yes No Has the horse received any joint injections, any type of medication long or short term, or any preventative treatments in the last 24 months? Yes No If other than gelding, are there any symptoms detrimental to satisfactory breeding? Yes No Is the horse currently on any type of medication? Yes No Are there any contagious diseases on the premises? Yes No Does the horse have any vicious habits? Yes No Are there any other medical facts that you feel should be brought to the attention of the company? Yes No Has the horse been tested for HYPP? Yes No Results: NN NH HH Appaloosas, Paints, and Quarter Horses are required to be tested if a progeny of the Impressive lineage; if sire or dam is NH or HH; or if animal's registration papers indicate NH or HH.ExplanationWhere did you hear about Albracht Insurance Agency LLP?I understand and agree that the policy to be issued shall be founded upon this representation of owner contained herein. Prior policy information and this representation of owner shall be the basis of the contract and if anything be falsely stated, or information withheld to influence the Company's decision, the insurance shall be null and void. ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME.Signature*Date
