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Horse Mortality Coverage - Request for Quote

Please complete the following information and click on the "Submit Request for Quote" button, below. A quote will be prepared and returned to you via email within 24-48 hours. Alternatively, you can print a copy of the Equi-Care Application, fill it in and mail or fax it back to us.

Contact Intercity Insurance at 905 841 8200 or email us if you have any questions.

Applicant Information
First Name of Applicant
Last Name of Applicant
Address 1
Address 2
City
Province
Postal Code
Phone ()   -
Cell Phone ()   -
Fax ()   -
Email Address
What Provincial Equine Association are you a member of?

Horse Information
Name Reg/Tatoo# Sex Breed Color Year Born
Sire Dam Date Acquired
YYYY         MM      DD		 Acquired From Purchase Price
or Stud Fee		 Use of Horse
Select Coverage Type
Full Mortality  Named Perils    		  Insurance Limit:
Optional Additional Coverages
MAJOR MEDICAL / SURGICAL *
Not Required 		   
Major Medical Insurance Limit $5,000   Flat charge $200 - $250 depending on Province
Major Medical Insurance Limit $10,000   Flat charge of $350
*Eligibility for Medical extension is limited to horses insured for Full Mortality and Valued $5,000 or more. Loss settlement will not exceed Mortality Limit.
 
Death Expense/Extra Stabling Expense   Insurance Limit: $1,000 / $2,500 Included
 
Tack and Equipment
Yes  No 		  Insurance Limit:
Minimum $25 premium
 
Stallion Infertility coverage is available for an additional premium.   Would you like a quote?    Yes  No
 
World Wide Coverage is available for an additional premum.   Would you like a quote?   Yes  No
 
Trailer
Yes  No 		  Insurance Limit:
Minimum $25 premium
Trailer Information
Make Model Year S/N
Are you the sole owner of the horse?
Yes  No 		  If no, please state the full details of designated parties and their financial interest (ie, Leasor, Syndicate, Payments on Purchase, etc.)
Is this horse current with all regular inoculations and wormings?
Yes  No 		   
Were there any illness or injuries to the above horse within the past 36 months?
Yes  No 		  If yes, please describe
Did any horse die or sustain injury while in your care or custody in the last 36 months?
Yes  No 		  If yes, please describe
Any insurance claims in the last 5 years?
Yes  No 		  If yes, please describe
Has any insurance company ever cancelled or refused any insurance of any type to you?
Yes  No 		  If yes, please explain
Have you claimed Veterinary Expenses in the last three years?
Yes  No 		  If yes, please explain
Is the above horse currently insured?
Yes  No 		  Insurer
  Policy Number
  Expiry Date
Individual/stable who cares for this horse:
As Above		 Name
  Address
Phone

DECLARATION OF OWNER I/We understand and agree that the policy to be issued shall be founded upon the statements contained herein; that animals having heaves or vicious habits, that animals which are colickers or emphysematous or bleeders or blind or nerved at or above the fetlock or orphaned foals under 90 days of age are not insurable, that no operation shall be performed on the insured animal without the consent of the company unless the operation is necessary as a result of an insured peril. I/We understand and agree that immediate notice and full details of any lameness, illness, injury or death of the insured animal will be given to the insuring company. I/We agree that this application is the basis of the contract and if anything is falsely stated or information withheld to influence the company’s decision, the insurance contract shall be null and void. It is understood that the signing and filing of the application does not bind the company and no insurance shall be effective until this application is accepted by the company based on the information declared.

I have read the above DECLARATION OF OWNER and wish to submit a Request for Quote

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