Connaway and Associates Horse Insurance Application

NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED, SIGNED AND DATED BY THE APPLICANT. THIS IS NOT AN INSURANCE BINDER. All applications received pending insurance underwriter approval.
Call our office with any questions! 501-868-8084

office@connaway.net
Desired effective date:
Name

First NameLast Name
Business Name - include LLC, Inc, etc (if horses are owned or co-owned by the business)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
We have several insurance carrier options. Please select your preference.
Major Medical desired?
Please note any special request relating to the medical program below:
Major medical is not available with all policies. Please contact our office to learn about Colic Treatment/Colic Surgery and Surgical Only products.

If you are interested in Full loss of use or Accidental loss of use coverage, contact your agent for information and restrictions.
Air transit / extended terriorial coverage desired?
Country your horse is shipping from:
Estimated flight date:
Horse's name
USEF, USDF, or USEA number
Breed
Color
Sex
Year of Birth
How you will use your horse and level (i.e. Hunter,Jumper,Dressage)
Purchase year/month
Purchase price
Commission paid
If imported / list import fees including quarantine and tariffs:
Desired insured value
Is this horse leased? If yes, provide name, address, email and phone of the current owner. A copy of the lease agreement is required.
Is this horse on trial for purchase? If yes, provide name, address, email and phone of the current owner.
Important: An insurance policy is a legal contract between the insurance company (insurer) and the person or entity being insured (insured). All parties with a financial interest in the horse must be disclosed in the insurance application (ex:owner, co-owner, lessee, loss payee, etc…). The applicant must have a financial interest/insurable interest in the horse and the application and statement of health must be completed and signed by the applicant. Provide name, address, email and phone of each additional party.
How was this horse purchased?
If a trade was involved provide the name and USEF number of the horse traded
Will your horse be outside the continental US or Canada during the coverage period?
Country your horse is shipping to/from:
Has any insurer declined, restricted or refused to renew/ insure your horse?
Do you understand immediate notice must be given to the insurance company in the event of any injury, illness or disease of your insured horse?
1/ Are there any health, eye, heart, respiratory, neck, back, cervical or lameness issues?
2/ Has the horse been treated for hoof problems, founder/laminitis, or rotation of the coffin bone?
3/ Has the horse had any colic, ulcer, or intestinal disorder in the past 12 months?
4/ Has the horse ever had colic surgery? If yes, provide date(s) of surgery and the name of the facility in the section below.
5/ Has the horse been nerved or received surgical treatment for lameness?
6/ Has the horse been treated for, or have evidence of, sarcoids, tumors, or melanomas?
7/ Does the horse have any conformational defects, lameness, degenerative joint disease, arthritis, bone chips, navicular, OCDs, neurological disorders, or EPM?
8/ Has the horse been treated or examined by a veterinarian for other than routine care within the past year?
Explain any yes answers to questions 1-8
If a Pre-Purchase Exam or Pre-Lease Exam was performed you are required to disclose any medical condition or abnormality in the comment section below or provide a copy of the PPE or Pre-Lease examination report. TYPE NA (Not Applicable) if exam not completed.
I understand horse insurance policies are term insurance policies and pre-existing conditions are not covered unless presented to and explicitly accepted by the insurance underwriter.
I, the undersigned, understand and agree that the policy to be issued is based on the above statements and prior policy information. I declare to the best of my knowledge and belief that the above statements are true and complete and that I have not withheld any material information. If anything is falsely stated or information is withheld, the insurance contract will be null and void.
Signature
date signed
The applicant must have a financial interest/insurable interest in the horse and the application and health questions must be completed and signed by the applicant.

Applicant MAY NOT be a minor.
Should be Empty:

NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED, SIGNED AND DATED BY THE APPLICANT. THIS IS NOT AN INSURANCE BINDER. All applications received pending insurance underwriter approval.

Call our office with any questions! 501-868-8084