Contact
Information
Name
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Washington D.C.
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Zip Code
Telephone
Fax
Email address
How would you like
us to respond? (Select One)
Email
Phone
Fax
How did you learn
about Broadstone?
Horse Information
Breed
Age (based on January
1 of this year as birthrate)
Gender
Value you'd like
to insure for:
Please
note that the insured value you request may need
to be substantiated to the underwriters by purchase
price, competition record, or breeding record.
Use (Select One)
What is the
current and/or highest level of competition your
horse will be competing over the next 12 months?
If you selected Other,
please put use here
If you selected Show
(no jumping), please indicate type of showing
here
Major Medical and Surgical Coverages
Select just one of
the following three:
Major Medical/Surgical (up to $5,000 limit)
Major Medical/Surgical (up to $7,500 limit)
Surgical Only
Additional Coverages
Loss of Use
International Coverage
(for outside continental U.S. and Canada)
If you need international
coverage, please indicate what countries the horse
will be located in, and during what time period.
Please
indicate here any health problems (injury, illness,
accident, or disease) the horse has experienced.
Please note the problem, when it started, the
treatment, and resolution. Please note:
The underwriters may apply an exclusion to
the policy for any existing or pre-existing health
conditions.
Important:
While we will be happy to provide you with an
initial quote based on the information above,
the quote is not a guarantee of coverage. Also,
the quotation process is not a binder. If you
would like to bind coverage on your horse, you
must speak directly to an agent and provide the
required documentation for review.