Breeder's Insurance - Horse Application, Including Veterinary Certificate

VETERINARY CERTIFICATE OF EXAMINATION FOR MORTALITY INSURANCE

Horses being examined for insurance should be moved about outside the stall to demonstrate soundness of limb and freedom of movement. Careful observation and inquiry should be made as to housing conditions and the presence of contagious disease. This certificate should be completed by the examining Veterinarian to the best of his ability as a licensed Veterinarian. The completed certificate should be forwarded without delay.

I, do hereby certify that I am a graduate Veterinarian holding a current license as such to practice in the State of
and that I have this day examined:

Name:
Sire:			Dam:
Markings or tattoo number:
Owned by:

Pulse and respiration normal?		History or evidence of nerving?
Temperature normal?		Has horse been castrated?
Eyes clinically normal?		Has any surgery been performed on the horse?
Heart ausculated?		If mare, is she reported in foal?
History or evidence of bleeder?		If male, are both testicles evident?

If any surgery has been performed, describe type of surgery:

If surgery has been performed, has horse fully recovered?

Is there any likelihood of future danger to life or limb as a result of such surgery?

Any lameness or faulty conformation or other abnormal conditions?

Is the stabling adequate?

In your opinion or to your knowledge, are there any medical facts that should be brought to the attention of the company?

Is there evidence of vices or objectionable habits?

Has official E.I.A. Test been run?

Date:

Lab. No.

Result

Remarks:

Name	Age	Sire	Dam	Markings or tattoo number

Remarks:

The horses listed above are in my judgment fully acceptable according to the specific requirements listed on the front of this certificate, except as I may have commented above.