Please complete the following form, or call us toll free at the following number: 1-800-821-5558. 

NOTE: 1. Minimum  Premium for Mortality only is $150.

                  Minimum Premium for Mortality & Major Medical is $260.

          2. No Major Medical for horses over 15 years.

                  No new policies for horses over 18 years.

          3. Minimum Horse Value of $2500 is required for Medical-Surgical coverage.

            Thank you!                     Get an Application Starnet    or   AIG

*required fields
Personal Information
Name*:
Address:
City:
State*:
Zip:
Phone:
Please call me as soon as possible during business hours.
Fax:
E-mail*:
Equine Information
Horse's Name :
Breed*:	American Saddlebred Andalusian Appaloosa Arabian Arabian-Half Arabian-NSH Belgian Clydesdale Friesian Miniature Morgan NSH Paint Paso Fino Percheron Quarter Horse Saddlebred Tennessee Walker Thoroughbred Warmblood Other-Please specify in "Additional Comments"
Age*: (N/A for horses >18 yrs)
Sex*:	Stallion Colt Mare Filly Gelding
Use*:	Breeding only Barrel Racing Barrel Racing / Breeding Combined Training Combined Training / Breeding Cutting Cutting / Breeding Dressage Dressage / Breeding Halter Halter / Breeding Hunter/Jumper Hunter/Jumper / Breeding Other (not including jumping) Pleasure (not including jumping) Pleasure(not including jumping) / Breeding Racing Rearing (foal/young unbroken horse) Racing / Breeding Reining Reining / Breeding Roping Roping / Breeding Show Team Penning Team Penning / Breeding Western Pleasure / Breeding Western Pleasure
Value*:	$
This is the purchase price of a recently acquired animal. I calculated the fair market value with substantiation; scores, points, and appraisal.
Select Coverage or coverage Desired
Mortality/Theft                       (N/A for horses >18 yrs)	*Guaranteed Renewal/Agreed Value       (* not available with Emergency Colic Surgery)
Major Medical $2,500 $5,000 $7,500 $10,000 $12,500 None (N/A for horses >15 yrs - Includes Surgical)	Surgical Only $2,500 $5,000 $7,500 $10,000 None
Loss of Use (Values>$10,000) None Accidental Loss of Use #1 Loss of Use #2	Stallion Infertility
Other:            Emergency Colic Surgery
Notify Me By:
Phone   Fax   E-mail
Send info regarding farm, business, club, horse show/event. Add me to your regular email list.
I found your agency by:*
Please select an option from at least one of the four categories below.
1. Personal Referral:
Veterinarian Trainer I am a current or former customer	Horse Hauling Company Friend Other:
2. Internet Search Engine
Google Equine Search Engine	Yahoo Other:
3. Magazine
Equus Horse and Rider Super Looper USETA News Other:	Practical Horseman Dressage Today Chronicle of the Horse Arabian Horse Times
4. Event or Show
Please Specify:   I cannot remember the name of the Event or Show.
Additional Comments

• Horse Insurance
• Full Mortality & Theft
• No Vet Check
• Horse Insurance Estimate

  Agri-Risk Services, Inc.

Toll Free - 1.800.821.5558
Local - 913.897.1699
Fax - 913.897.1444
info@agririsk.com