Renewal Health Declaration | Affinity Equine Insurance

Insured (Your Name) *

Policy Number *

I hereby declare that I normally use the following Veterinary Practices: *

Horse Health Declaration

Horse Name *

How long has the horse detailed been in your ownership? *

Years

(1) Has the insured horse to your knowledge:

(a) suffered any accident, illness, disease, colic or fractured bone? *

Yes

No

(b) suffered from sprained tendons, been fired or de-nerved? *

Yes

No

(c) operated on for any wind condition or suffered a spell of coughing? *

Yes

No

(d) ever suffered any irregularity of the heart? *

Yes

No

(e) ever suffered skin conditions, allergies, sarcoids or warts? *

Yes

No

Please provide details on the above declared information

(2) Has the horse received any treatment other than normal vaccination, in the past 12 months *

Yes

No

Please provide details on the treatment received

If you have made a claim in the past 12 month period please confirm the injury/illness is fully resolved and requires no further treatment and also has not rendered the horse lame and/or unsound in any way *

Yes

No

Please provide details:

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Should it be necessary I give my permission for all facts relating to any past veterinary treatment of this horse/pony to be disclosed for the purposes of insurance with the above company.

To the best of my knowledge and belief all facts relating to the above horse's conditions during the past 12 months have been fully disclosed. I hereby declare that the animals described in this document is in a good state of health and any other facts relating to this policy which may effect the insurance have also been included.