* E-Mail

* Input E-mail                                                  again

*State

*Zip Code

Country

Please Select One ----> Email Phone FAX Postal Contact me by:                                               

*Breed of horse?

If Breed Is AQHA, Paint or Appaloosa, we need to have the following Questions Answered. Has the horse been tested for HYPP?

Please Select One ----> NA yes tested not tested Has the horse                                     been tested for HYPP?

Please Select One ----> NA Dont Know NN NH HH Results of                                                HYPP test?

Quarter horses, Paints and Appaloosas are required to be tested. Certainly, if a progeny of the Impressive lineage; if sire or dam is NH or HH; or if animal's registration papers indicate NH or HH for HYPP. Eligibility for insurance depends on HYPP status.

*Name of horse?

*Sex of horse?

*Age of horse?

Please Select One ----> Select Breeding Foal/Weanling (Req D.O.B.) Yearling Pleasure Show Halter Show Western Pleasure Show English Pleasure Show Country Pleasure Show Hunter Under Saddle Dressage (no jumping activities) Driving Show Hunter HunterJumper (under 4,6") Show Jumper Eventing (Training Level & below) Eventing (Preliminary Level & up) Flatracing Field Hunter Fox Hunter Endurance/Distance Cutting Team Penning Reining Roping Barrel Racing *Use of horse? ?

Other use of                                               horse?

Value of                                               horse?

QUOTE ADDITIONAL COVERAGE FOR THIS HORSE:

12-Month Guarantee Extension - Mortality

Emergency Colic Surgery Extension

Major Medical/Surgical (Age restrictions apply) Quote Limit Please Select One ----> 5000 7500 10.000

Surgical Only Coverage (Age restrictions apply)
Quote Limit Please Select One ----> 5000

Stallion Accident, Sickness, Disease Infertility (not available first year stallions)

Loss of Use (Requires Major Medical & Surgical Coverage. Loss Of Use Coverage is available ONLY for Show Use with the exception of Halter, Western Pleasure, Eventing, Field Hunters, Barrel Racing, Endurance/Distance, Cutting, Team Penning, Reining and Roping.”)
Loss of Use Please Select One ----> External injury loss of use Full loss of use

To Complete Insurance Process for an Immediate Binder (An insurance binder provides temporary coverage while the original application, other required forms, and premium are sent to us through the mail.) Fax completed forms to (502) 493-0070 or Mail to: Smith-Embry Insurance Associates, 3044 Breckenridge Lane; Suite LL1; Louisville, KY 40220-2193

Requirements:Completed, Signed, Dated Application. Veterinary Certificate (values over $25,000). Health Statement (values $25,000 or less)' Justification of Value & Premium Payment

Submit A New Form For Each Horse You Require A Quote...