Equine Online Quote

Client Details

First Name

Surname

ID Number / Passport No

Email Address

Contact No

Have you had any claims/losses in the past two years?

If Yes, please give details

Details of horse to be insured

Name

Breed

Date of birth

Sex

Color

Purchase Price

Value for Insurance

Passport No

Microchip No

Discipline

Address where horse is stabled

Is the horse registered?

Organisation and no

Is the horse stabled with a professional trainer?

Name of person responsible for your horse/trainer

Cell Number

Mortality Cover

Loss of Use - Please specify one discipline for LOU

Discipline for Loss of Use

Emergency Veterinary

The Amount needed cannot be more than double the value of the horse. Maximum limit of R200 000

Emergency Veterinary Amount

Personal Accident Cover

Public Liability - R1 000 000

Claims Preparation

Day to day medical cover - R 50 000

Veterinary Practise Details

Name of Veterinary Practise

Vets Name

Tel Number (W)

Cell Number

Please Note:

Loss of Use must be taken together with Mortality Cover and will only cover loss for one discipline, which must be specified upfront.
Veterinary certificates are required for values of R100 000 and above, or as otherwise required.
Loss of Use always requires a veterinary certificate, regardless of value. The certificate must confirm whether the horse is considered a good risk for that particular discipline.

Inception Date

Declaration of Health

If you answer YES to any health related questions, please provide further details in the field below

Has the proposed animal described suffered any accident, sickness (incl Biliary), disease, lameness, colic, sprained tendons, been fired or denerved, operated on for wind or respiratory defects or been on any course of medication or received any veterinary attention? If yes, please supply details. Dates and amounts.

Yes

Has the proposed animal described suffered any fractures, tendon/ligament injuries, ringbone or chronic lameness within the last 12 months?

Yes

Has the proposed animal been treated for melanomas, sarcoids or growths of any kind for the last 12 months.

Yes

Has the proposed animal suffered any accident?

Yes

Has the proposed animal undergone colic surgery?

Yes

Is the proposed animal seen by a dentist regularly?

Yes

Does the proposed animal suffer from faulty conformation or any other congenital defects?

Yes

Has the proposed animal ever failed a veterinary examination?

Yes

Has the proposed animal been vaccinated against Horse Sickness, Influenza and Tetanus?

Yes

Is the proposed animal described herein, clinically healthy and in good condition?

Yes

Are you currently Insured?

Yes

Which which insurer is the horse currently insured?

Has any Insurer ever declined a proposal, refused renewal, required special premiums or imposed special exclusions or terms?

Yes

Important

All material facts must be disclosed. Failure to do so may result in the policy being nullified in the event of a claim.
Horses valued at R100 000 and above require a Veterinary Certificate of Health at inception.
You may be required to provide a Veterinary Certificate of Health if you have answered YES to any of the health-related questions above.
Horses aged 20 years and older require a Veterinary Certificate of Health on an annual basis.
All pre-existing conditions prior to inception, and any consequences thereof, are specifically excluded.

Declaration

I hereby request that the Insurers provide insurance cover in terms of this Mortality cover and its extensions.

I declare that the above answers are true and correct, and that I have not withheld any information that may influence the Insurers’ decision regarding this proposal. I undertake to exercise all ordinary and reasonable precautions for the safety and well-being of the insured animal.

I agree that this proposal and declaration shall be deemed promissory and shall form the basis of the contract between myself and the Insurers. If any information is untrue, or if any material information that could influence the Insurers’ decision is withheld, any resulting contract or agreement shall be rendered void.

Declaration(Required)

I declare the information correct.

I hereby declare that the horse described above is in good health and condition and to the best of my knowledge and belief has not suffered any illness, injury, disease or any other condition during the past 12 months as stated above.

Signed at

Signed Date

Signature

Equine Online Quote

Client Details

Details of horse to be insured

Veterinary Practise Details

Declaration of Health

MiSure Brokers