disability in the last 36 months? No Yes

LIVESTOCK MORTALITY APPLICATION AND STATEMENT OF HEALTH FORM

(THIS IS NOT A BINDER) Applicant: Address: City: State: Zip: Telephone: (Day)

(Cell) Fax: E-mail:

COVERAGE REQUIRED: $1,000 Deductible $500 Deductible

$1,000 Deductible $500 Deductible $1,000 Deductible $500 Deductible

Stallion Permanent Disability† Single Air Transit Worldwide Coverage

†Requires Vet Certificate

$5,000 Major Medical $7,500 Major Medical $10,000 Major Medical $15,000 Major Medical $5,000 Surgical

PAYMENT OPTIONS Full Payment Four Payment Plan (25% down payment attached) IF AVAILABLE Auto-Pay

Check Credit Card # Exp. Date: MC, VISA, AMEX or DISC. Sorry, we do not accept Diners Club.

NAME OF HORSE OR PEDIGREE IF UNNAMED

REG. NO. OR COLOR

SEX (E.G. Colt Gelding)

BREED USE DATE OF

BIRTH DATE OF

ACQUISITION STUD FEE OR

PURCHASE PRICE AMOUNT OF*

INSURANCE DESIRED

A.

B.

C.

D.

1) Is there any insurance applying to the horse listed? No Yes

2) Does anyone else have interest in the horse? No Yes If yes, please provide name and address.

3) Has the horse had any colic or intestinal disorder within the last 36 months andif a surgical correction was made, was there a resection? No Yes

*VALUES OTHER THAN THE PURCHASE PRICE ARE SUBJECT TO ACCEPTANCE BY THE COMPANY. DETAILS OF PRIZE WINNINGS, PERFORMANCE, SERVICE FEES, NUMBER BOOKINGS AND OTHER PERTINENT INFORMATION MUST BE SUBMITTED FOR CONSIDERATION OF STATED VALUES (use below for details).

REMARKS / COMMENTS / SHOW RECORD:

4) Has the horse listed had any illness, disease, lameness, injury, accident, or physical

5) Has there been any contagious or infectious disease at the farm where the horse is kept? No Yes

10) If horse listed is a mare, is she in foal? No

If horse listed is a stallion, what is his current stud fee?Bookings for current year: Bookings for previous year:

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 purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and substantial civil penalties.

I declare to the best of my knowledge and belief that the horse(s) listed on the above application to be in normal healthy sound condition. I further declare that during the past twelve (12) months the above listed horse(s) have been free from any ILLNESS, INJURY, DISEASE, or ACCIDENT. I hereby certify that the above information is truthful and accurate. I understand that any fraudulent, omitted or misrepresented statement voids any policy of insurance issued on the basis of this application. I further understand that the insurer will rely on the information provided in this application, which will become part of any policy issued.

I also understand that it is required under the policy to give IMMEDIATE notice by telephone of any illness, injury, disease or death of any insured horse. Not doing so may jeopardize coverage and result in denial of any claim made.

I/we confirm no similar insurance has ever been declined or cancelled. I/We understand and agree that the policy to be issued shall be founded upon the statements contained herein, and this statement shall be the basis of the contract, and if anything be falsely stated or information withheld, the insurance shall be null and void.

8) Is the horse currently sound and healthy for its intended use? Yes

$1,000 Deductible $500 Deductible $7,500 Surgical $15,000 Surgical

Life Saving Surgeries ($10,000 with a $100 Deductible)

Signature Date

6) Has the horse been examined or treated by a veterinarian for other than routine care inthe last 36 months? No Yes If yes, by whom and what was the nature of the visit?

9) Is the horse up to date on vaccination against the West Nile virus (WNV)?

7) Have any animals in your ownership died in the past 36 months?

Yes

FOR ANY QUESTIONS 1-7 ANSWERED YES, PLEASE EXPLAIN IN SPACE PROVIDED.

NO APPLICATION WILL BE CONSIDERED IF NOT FULLY COMPLETED AND SIGNED BY THE ASSURED WITHIN 10 DAYS OF INCEPTION.

If yes, to whom and when is she due?

No Yes

No Yes

CSC:

49 East Garfield Road • Aurora, Ohio 44202 • U.S.A. Telephone: (440) 248-5330 • Facsimile: (440) 248-8737 • info@jarvisinsurance.com

www.jarvisinsurance.com