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Equine Insurance Form
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Insured 1 - First Name
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What is your first name? *
Insured 1 - Last Name
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What is your last name? *
What is your email address? *
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What is your email address? *
What is your phone number? *
*
What is your phone number? *
What is your mailing address. *
*
What is your mailing address. *
Street Address
Address Line 2
City
State
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American Samoa
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Colorado
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Delaware
District of Columbia
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Guam
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Louisiana
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Maryland
Massachusetts
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Minnesota
Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What is the horse stabling address? *
*
What is the horse stabling address? *
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What breed is the horse?
What breed is the horse?
What is the age of the horse?
What is the age of the horse?
Is the horse Mare/Gelding/Stallion?
Is the horse Mare/Gelding/Stallion?
Mare
Gelding
Stallion
Is the horse used for breeding or currently in foal?
Is the horse used for breeding or currently in foal?
Breeding
In Foal
Use of horse?
Use of horse?
What discipline is the horse currently being used for?
What discipline is the horse currently being used for?
Hunter jumper
Dressage
Eventing
Fox hunting
Reining
Cutting
Trail riding
Other
Please explain the other discipline the horse is being used for.
Please explain the other discipline the horse is being used for.
Purchase price?
Purchase price?
Requested mortality insurance limit?
Requested mortality insurance limit?
Requested medical insurance limit?
Requested medical insurance limit?
$5,000
$7,500
$10,000
$15,000
Any existing medical conditions?
Any existing medical conditions?
Horse Insurance?
Is the horse currently insured?
Yes
No
Horse Insurance Carrier Name
What carrier?
Documents and Comments
Horse Comments
Please enter comments about the horse or any current conditions of the horse below.
Referral Source
Please share who referred you to us.
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 25.
Consent
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree*
Dan Gorman
(631) 228-7818
https://coastalinsurancesolution.com
dgorman@clausenagency.com
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