Veterinary Certificate of Examination for Mortality Insurance

Veterinary Certificate of Examination for Mortality Insurance

Connaway and Associates: 501 868 8084; office@connaway.net; fax: 501 868 8067
Horses being examined for insurance should be moved about outside the stall to demonstrate soundness of limb and freedom of movement. Careful observation and inquiry should be made as to housing conditions and the presence of contagious disease. This certificate should be completed by the examining veterinarian to the bes of his/her ability as a licensed veterinarian. The completed certificate will be emailed to Connaway and Associates Equine Insurance Services Inc.
I, do hereby certify that I am a graduate veterinarian holding a current license to practice.*

First NameLast Name
Veterinary license(s) held in the State(s) of: *
Horse Name*
Age of Horse*
Color*
Sex*
Breed*
Intended use of the horse:*
Owner Name:*

First NameLast Name
YesNo
YesNO
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNoNA
YesNo
YesNoNA
YesNoNA
Date last dewormed: *
How often dewormed:*
If any surgery has been performed (other than castration), describe type of surgery and date:*
If surgery has been performed, has horse fully recovered?*
Is there any likelihood of future danger to life or limb as a result of such surgery?*
Any lameness or faulty conformation or other abnormal conditions?*
Is stabling adequate?*
I there evidence of vices or objectionable habits?*
In your opinion or to your knowledge, are there any medical facts that should be brought to the attention of the company?*
Are you the regular veterinarian for this horse or client?*
EXCEPT AS NOTED ABOVE, I HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THE HORSE IS, EXCEPT AS NOTED ABOVE, SOUND FOR IT'S INTENDED USE.
Additional remarks:*
Email of veterinarian *
example@example.com
Address of veterinarian:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Examining Veterinarian*

Powered by Jotform SignClear
Date of Examination*
Should be Empty: