Affinity Health Declaration Equine Protection - Health Declaration Your Name * Policy Number * I am completing this health declaration for? * Please SelectRenewalAdding Veterinary Fee cover to my policyIncreasing the Mortality sum insured for my horse Veterinary Fee Cover Please Select$7,500 limit per year ($500 excess each and every loss)$10,000 limit per year ($500 excess each and every loss)$10,000 limit per year + $5,000 Emergency Colic Surgery Extension ($500 excess each and every loss) I hereby declare that I normally use the following Veterinary Practices: * Valuation Requirements Valuation Required &/or Veterinary Certificate If you have owned your horse for a period longer than 30 days, you will need to please source an independent valuation (requirements below). The valuation must be provided on typed letterhead, dated (within the last 30 days), with the valuer’s full name, signature, email, postal address and phone number.The valuation may be issued by an independent & reputable judge, breeder, trainer or similar and should include the following:- (please note we do not accept valuations provided by vets) Details of the person providing the valuation* Full contact details including address, email and phone number* Qualifications, accreditation* Relationship to owner of horse Details of the horse* Name, age, pedigree, colour, etc.* Discipline (ie dressage, show jumping, etc.)* Performance record (if applicable) Reasons supporting the value provided* ie - superior bloodlines, performance history, etc. Supporting Valuation Documentation - File Upload Drop a file here or click to upload Choose File Maximum file size: 52.43MB 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: plus1 Add Horse To Declaration minus1 Remove Horse From Declaration 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. Submit Declaration If you are human, leave this field blank. Δ
