HORSE & CARRIAGE
POLICY RENEWAL FORM

Please complete the following sections as applicable

If you are under 18 years old, this form must be signed by your parent,
guardian or legal representative
Your Details
    Insured name:
    Post Code:
    (If you have moved address in the period since taking out the policy please specify the old postcode here and submit the your new postcode in the comment field at the bottom of the page)
    Policy Number:
    Annual price of Policy
    Please fill in the amount listed on your policy.
    Email address of Policy Holder

DECLARATION:
(Tick to boxes to confirm)

I / We declare that there has been no material changes in the risk since the inception of the policy or the last renewal date whichever was later.

I / We declare that all the statements made in the proposal are true to the best of my/our knowledge and belief and that this renewal form shall form the bases of the contract between me/us and the insurer and that I/we will accept and abide by the terms and conditions of the policy issued.

Date: Thu 15th May 2008

Additional Questions:

If you have any horses insured for death and theft please also answer the questions below.
 
    A Have any of the above horses suffered from colic or any other related illness at any time to the best of your knowledge ? Yes No
      If YES has the animal made a complete recovery ? Yes No
    B Have the horses suffered from any lameness, injury, illness or disease or undergone any surgery at any time to the best of your knowledge ? Yes No
      If YES has the animal made a complete recovery ? Yes No
    C Has there been any evidence of contagious or infectious diseases during the past 12 months at the stables/barn where the horses are kept ? Yes No
    D Have any of the horses been fired, blistered, nerved, operated on or received treatment for lameness (other than sore shins) at any time to the best of your knowledge or does the horse have faulty confirmation ? Yes No
    E Are the above horses at present normal in eye, wind and action to the best of your knowledge and does it in your opinion represent a normal risk for mortality insurance purposes ? Yes No

NOTES:
If you answered YES to questions A to D please provide details in the notes box below stating the names of the horse(s) to which the notes apply.

I / we hereby certify that to the best of my/our knowledge & belief the above particulars are true and correct and that no information has been withheld.