Full Name:*

Telephone No:*

Owner, Manager, Trainer, or Other:*

Address*

Email*

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Name of Horse*

Colour*

Sex*

Sire

Dam

Year of Birth*

Passport Number / Microchip Number*

Use*

Owner*

Stabled at/Trainer*

How long has the horse been at its current location?

Years*

Months*

List previous locations under current ownership:

Your duty of disclosure

You must take care when answering any questions we ask by ensuring that all information provided is accurate and complete. You have a duty to disclose to us all material facts that we may rely on when setting the terms of the policy or accepting coverage.

If you do not tell us something

If we establish that you have failed to comply with this duty of disclosure or provided us with incorrect or incomplete information that we have relied upon when accepting this coverage, we may refuse to pay your claim or reduce the amount payable to you. If the non-disclosure is fraudulent then we may treat your policy as if it never existed and decline all claims.

Please email all relevant veterinary reports regarding any problems mentioned to newmarket@lycetts.co.uk

Please answer the following questions to the best of your knowledge and ability by ticking the appropriate box

1) Has the above horse to your knowledge ever suffered from any form of colic or other intestinal or digestive disorder?*

Yes
No

2) Has the above horse to your knowledge undergone any surgery (including castration if within the last twelve months)? Is there any external evidence that the horse has undergone abdominal surgery?*

Yes
No

3) Has the above horse to your knowledge ever suffered from any lameness, fractures, tendon or ligament injury, or been de-nerved? Or needed to be box-rested or x-rayed for lameness?*

Yes
No

4) Has the above horse to your knowledge ever suffered from melanomas, sarcoids, warts or any other type of growth?*

Yes
No

5) Has the above horse to your knowledge ever had any other accident, illness or disease other than those mentioned in Questions 1, 2, 3 or 4 above?*

Yes
No

6) Has there to your knowledge been any evidence of contagious or infectious disease during the past twelve months in the location where the horse is kept?*

Yes
No

7) During the last twelve months has the above horse received attention from any Veterinary Surgeon or Paravet for any reason other than routine vaccination or obstetric work, or received any other form of treatment for remedial purposes including farriery, maintenance injections or shockwave therapy. Has the horse received steroidal, non-steroidal, anti-inflammatory or analgesic medication?*

Yes
No

8) To the best of your knowledge is the above animal normal in conformation, eyes, heart, wind and action and in good health?*

No
Yes

9) STALLIONS ONLY To the best of your knowledge and belief are the external genitalia of the above animal of normal size and consistency?

Yes
No

10) BROODMARES ONLY Has she had any pregnancy, foaling, or post-foaling problems or received veterinary attention for the same?

Yes
No

11) BROODMARES ONLY Is there any evidence or history of a pelvic fracture?

Yes
No

If you have ticked any of the boxes in the left hand column, please complete below

Please fill in the below box with the following information:

Date of Problem
Type of Problem
Treatment Details
Recovery Status

Would you like a copy if this form emailed to you?

Yes

Declaration of Health

To be completed and signed by the owner or person responsible for the horse

Your duty of disclosure

If you do not tell us something

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