(1) Applicant (2) Address   City   State   Country   Zip (3) Telephone Days Eves   PAYMENT OPTIONS Full Payment Payment Plan

Email Address   COVERAGE REQUIRED Full Mortality   $2,500 Surgical Specified Perils   $5,000 Surgical Loss of Use   $7,500 Surgical SPD   $5,000 Major Medical       $7,500 Major Medical       $10,000 Major Medical Other     12 MONTH EXTENSION (Please choose and initial)  I Accept  I Reject the 12 Month Extension Endorsement on eligible horses at $25.00 per horse. Initials:

A	Name of Horse or Pedigree If Unnamed Reg. or Tatoo No. Sex (e.g. Colt, Gelding, etc) Breed
	Use & Color Date of Birth Date of Acquisition Auction or Private?
	Stud Fee or Purchase Price Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

B	Name of Horse or Pedigree If Unnamed Reg. or Tatoo No. Sex (e.g. Colt, Gelding, etc) Breed
	Use & Color Date of Birth Date of Acquisition Auction or Private?
	Stud Fee or Purchase Price Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

C	Name of Horse or Pedigree If Unnamed Reg. or Tatoo No. Sex (e.g. Colt, Gelding, etc) Breed
	Use & Color Date of Birth Date of Acquisition Auction or Private?
	Stud Fee or Purchase Price Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

D	Name of Horse or Pedigree If Unnamed Reg. or Tatoo No. Sex (e.g. Colt, Gelding, etc) Breed
	Use & Color Date of Birth Date of Acquisition Auction or Private?
	Stud Fee or Purchase Price Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

E	Name of Horse or Pedigree If Unnamed Reg. or Tatoo No. Sex (e.g. Colt, Gelding, etc) Breed
	Use & Color Date of Birth Date of Acquisition Auction or Private?
	Stud Fee or Purchase Price Amt. of Insurance Desired

[No More Horses, Skip to Next Step]

F	Name of Horse or Pedigree If Unnamed Reg. or Tatoo No. Sex (e.g. Colt, Gelding, etc) Breed
	Use & Color Date of Birth Date of Acquisition Auction or Private?
	Stud Fee or Purchase Price Amt. of Insurance Desired

APPLICANT MUST COMPLETE ALL QUESTIONS AND "SIGN" BELOW. ANY QUESTIONS ANSWERED "YES" PLEASE EXPLAIN IN SPACE PROVIDED. (4) Is there any other insurance applying to horse(s) listed?  No     Yes If "Yes", an explanation is REQUIRED.   (5) Does anyone else have any interest in the horses(s) listed? (include name & address)  No     Yes If "Yes", an explanation is REQUIRED.   (6) Has any insurance co. cancelled or declined similar insurance?  No     Yes If "Yes", an explanation is REQUIRED.   (7) Has any of the listed horse(s) had any illness, disease, lameness, injury, accident or physical disability in the past 2 years?  No     Yes If "Yes", an explanation is REQUIRED.   (8) Has there been any contagious disease on your premises during the past year?  No     Yes If "Yes", an explanation is REQUIRED.   (9) Have any horse(s) in your care of ownership died in the past 2 years?  No     Yes If "Yes", an explanation is REQUIRED.   (10) Mare in foal?  No     Yes If "Yes", sire is REQUIRED. to whom STUD FEE   (11) Stallions: A) Present stud fee  B) No. of bookings this season  C) No. of mares serviced last year

REMARKS / COMMENTS / SHOW RECORD NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the pur pose of misleading information concerning any fact material, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties. NOTICE: No animal will be bound for the full mortality until: a) This application has been property completed and received by this office; AND b) A current vet check covering such animals has been received by this office. Pending actual receipt of any such vet check, this office will bind coverage against Named Perils Only. c) Premium Payment with application - minimum payment is $150.00. I declare the animal(s) as shown on the schedule to be in good health and condition and warrant the truth of the above statements. I agree this application shall be the basis of the contact and if anything be falsely stated or information withhold to infl uence the company's decision, the insurance contract will be null and void. APPLICATION AND VET EXAM MUST BE IN OUR OFFICE WITHIN 15 DAYS OF VET EXAMINATION DATE Signature: ___________________________________________ Date: _______________________________________________