Statement of Health Form - Albracht Insurance

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Springtown, Texas

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SOH-Albracht Insurance Agency LLP

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STATEMENT OF HEALTH

This 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 Horse

How long have you owned horse?

Name of Insured

First Last

Age / Breed / Sex / Use

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Email*

If female, is she in foal?

Yes

Estimated Foaling Date:

Has the horse been castrated?

Yes

If male, are both testicles visible?

Yes

If any of the following are answered "NO," please explain.

Pulse/respiration normal?

Yes

Temperature normal?

Yes

Is stabling adequate?

Yes

Explanation

Is the horse currently free of lameness and healthy, without the use of drugs, for the use intended?

Yes

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

Has the animal suffered any illness or injury in the last 12 months?

Yes

Has the horse had any colic, impaction, colic surgery or intestinal disorders within the last 36 months?

Yes

Has the horse been nerved or received any surgical treatment for lameness?

Yes

Has any type of surgery been performed?

Yes

Has the horse undergone diagnostic ultrasound, bone scan, or x-rays within the last 36 months?

Yes

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

If other than gelding, are there any symptoms detrimental to satisfactory breeding?

Yes

Is the horse currently on any type of medication?

Yes

Are there any contagious diseases on the premises?

Yes

Does the horse have any vicious habits?

Yes

Are there any other medical facts that you feel should be brought to the attention of the company?

Yes

Has the horse been tested for HYPP?

Yes

Results:

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.

Explanation

Where 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

MM slash DD slash YYYY

Equine Application Insurance:
Fill out Online or Download and fill out

Statement of Health:
Fill out Online or Download and fill out

Veterinary Certificate of Examination -

Download

Foal Insurance Exam Form-

Download

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Association / Club
Care, Custody & Control Application
Cattle Questionnaire

CGL
Event

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Albracht Insurance Agency LLP

P.O. Box 999
Springtown, TX 76082
Toll Free 800-227-8808
Fax 817-523-4258

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