Bar H Insurance

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To request a quote, please fill out this form.

Please Fill Out The Form Below

Name

Mailing Address

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

Phone

E-mail

Individual

Partnership

Corporation

Joint Venture

Limited Liability Corp.

Other

Proposed Effective Date

Reaquired field: New Policy

Reaquired field: Endorcement

Animal Name

Date of Birth

Date of Purchase

Purchase Price

Requested Limit of Insurance

Identification

Sex

Breed

Use

Primary Stable Location

Address

City

State / Province / Region

Zipcode Min: 1 Max: 5

Country

ALL LIMITS OF INSURANCE ARE SUBJECT TO COMPANY APPROVAL **For a requested limit of insurance that does not equal the purchase price, complete and attach a Substantiation of Value**

Type of Coverage requested

Reaquired field: Mortality- Full

Reaquired field: Mortality- Limited

2. Has the Horse been examined or treated by a veterinarian for any accident, injury, sickness, disease, lameness, or other than routine care within the last year?

Reaquired field: Yes

Reaquired field: No

3. Is the horse currently free of lameness and healthy without the use of drugs?

Reaquired field: Yes

Reaquired field: No

4. Has the horse undergone diagnostic ultrasound, bone scan, or x-rays within the last 36 months?

Reaquired field: Yes

Reaquired field: No

5. Does the horse have any past confirmational problems or defects, illness, or disease, lameness, or injury or physical disability including, but not limited to: laminitis/founder, OCD, neurological disorders (e.g. EPM), navicular disease, and/or degenerative joint disease? Copy

Reaquired field: Yes

Reaquired field: No

6. Has the horse been nerved or received any treatment for lameness?

Reaquired field: Yes

Reaquired field: No

7. Has the horse received any joint injections, any type of medication long or short term, or any preventative treatments in the last 36 months?

Reaquired field: Yes

Reaquired field: No

8. Has the horse had any colic, colic surgery, impaction, or intestinal disorder within the last 36 months?

Reaquired field: Yes

Reaquired field: No

9. Is the horse due to foal any time during the requested policy period?

Reaquired field: Yes

Reaquired field: No

If yes, please give the estimated foaling date, number of previous foals, and the stud fee

10. Has the horse ever experienced birthing difficulties?

Reaquired field: Yes

Reaquired field: No

11. Does the horse have an ancestor known to carry HYPP?

Reaquired field: Yes

Reaquired field: No

a. Has the horse been HYPP tested? Copy

Reaquired field: Yes

Reaquired field: No

b. Has the horse ever shown any HYPP signs or symptoms?

Reaquired field: Yes

Reaquired field: No

12. Will the horses be observed and cared for daily?

Reaquired field: Yes

Reaquired field: No

13. Who was the horse acquired from?

14. Are you the sole owner of the horse? If no, provide other owner's % of interest, name, and address. Copy

15. Loss Payee(s):

16. If the purchase price was not paid entirely in cash, please describe the transaction.

17. Are the horses leased to others?

Reaquired field: Yes

Reaquired field: No

18. Is there any other insurance on the horse?

Reaquired field: Yes

Reaquired field: No

a. Amount of coverage Copy

b. Expiration Date

c. If yes, provide the carrier name

19. Has any insurance carrier ever canceled, non-renewed, or refused to insure any horse in which you have or had an insurable interest?

Reaquired field: Yes

Reaquired field: No

20. Have you lost any horse in the last 5 years (whether or not insured) or have any medical/surgical or colic claims been filed on the above listed horse?

Reaquired field: Yes

Reaquired field: No

a. If yes, give date, cause, value, and explain:

21. Name, address, and telephone number of the horses primary veterinarian

22. Do you understant that the insurance policy you are applying for requires you to give the company immediate notice of any covered animal's death, injury, sickness, or disease, along with a description of the condition and the name of the attending veterinarian? Do you also understant that failure to give this immediate notice may result in the denial of a claim?

Reaquired field: Yes

Reaquired field: No

Please provide any additional information:

Note: A Veterinarian Certificate of Exam IS required if: 1. Horse is under 6 months of age 2. Horse is over 16 years of age 3. Horse is valued over $50,000 4. You have not known the horse for over 30 days (A pre-purchase exam no older than 30 days may be submitted in place of the vet exam)

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Required Fields

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Contact Information

Bar H Insurance
4926 S Wards Chapel Road
Atoka, Oklahoma 74525

Map

Phone: 580-364-0151
Mobile: 580-364-6885;580-364-2623
Fax: 580-207-6065

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