Proposal For First Season Infertility Insurance
Note: Losses due to genital tract infections of the stallion are not covered by this policy. This
is because such losses are not Congenital Infertility within the meaning of this policy and are
more appropriately included in available ‘Permanent Infertility (Accident, Sickness and
Disease)’ policies, when infection damage is both permanent and total, or by ‘Loss of Income’
policies, when infection damage is temporary.
1. Name and Address of Proposed
Assured:
2. Name of Proposed Insured
Stallion:
Year of Birth of Proposed Insured
Stallion:
3. Name and Address of Farm
where Proposed Insured Stallion is
presently maintained:
Name and Address of Principal of
this Farm:
Name and Address of Manager of
this Farm:
4. Name and Address of Stud
Farm where Proposed Insured
Stallion is to stand:
Name and Address of Principal f
this Farm:
(i) Number of Years of Ownership
or Management at this Stud Farm:
(ii) Number of Years in
Thoroughbred Breeding Business:
Name and Address of Manager of
Stud Farm:
(i) Number of Years of
Management at this Stud Farm:
(ii) Number of Years in
Thoroughbred Breeding Business:
Where and by Whom will the
Proposed Insured Stallion’s
records be kept:
5. Has Proposed Insured Stallion
ever raced or been trained for
racing:
Yes / No

If yes, annex as addendum a schedule of
racing history including races entered, race
result and winnings, separately designating and
claiming races.
If yes, state when horse went out
of training:
6. State the date that the horse
arrived or is due to arrive at the
Stud where it will stand:
State the date the Proposed
Insured Stallion is scheduled to
begin stud duties:
7. Has Proposed Insured Stallion
been semen tested or test bred:
If so, when and what were the
results:
8. Will Proposed Insured Stallion
be semen tested or test bred prior
to covering season:
If so, when:
Yes / No
9. Have Anabolic Steroids ever
been administered to the Proposed
Insured Stallion:
If yes, please give details of when
and what was administered:
10. Is current Code of Practice for
venereal disease adhered to:
11. How many mares will the
Proposed Insured Stallion cover
during First Season at Stud:
State the maximum number of
mares the Proposed Insured
Stallion may normally be asked to
cover in one week:
State the maximum number of
mares the Proposed Insured
Stallion may normally be asked to
cover in one day:
12. Are Walk-In mares accepted
at Stud:
How many in respect of Proposed
Insured Stallion:
13. Is there a resident Vet at the
Stud:
Full name of this Vet or name and
address of usual Vet and distance
from the Stud:
14. State whether Proposed
Assured is Sole and Exclusive
Owner of Proposed Insured
Stallion to the extent of 100%
ownership, currently vested and
not subject to any condition
relating to or based upon, in whole
or in part, the fertility of the
Proposed Insured Stallion:
Yes / No
15. State whether Proposed
Assured is sole and exclusive
owner of Proposed Insured Stallion
to the extent of 100% ownership,
currently vested and not subject to
any condition relating to or based
upon, in whole or in part, payments
required pursuant to any purchase
or sale agreement:
16. If questions numbers (14) and
(15) above are not answered “Yes”
and without qualification, then
please provide the following:
If ownership of Proposed Assured
is less than 100%, state the
percentage ownership:
Is the Proposed Insured Stallion
subject to any form of Syndication
Agreement:
If yes, number of shares:
If yes, detailed breeding rights:
If yes, specify sale price each
share (without inclusion of
valuation for breeding rights):
Set forth details of deferred
payment terms:
Set forth details of Warranties
given:
If yes, does there exist any
agreement under which ownership
interest of the Proposed Assured
will or may be modified or altered
in the event of injury or infertility:
I hereby declare that the above statements are true and complete. I make this proposal with
knowledge that any insurance policy to be issued will be based on the statements contained
herein, and such statements shall, in the policy, be deemed warranties and representatives,
as shall the statements contained in any veterinary certificate supplied in furtherance of this
proposal.
Signing this form does not bind the proposed insured to complete the insurance, nor does
receipt of the proposal bind any insurer to accept the same.
Signature Of Proposed Assured:
Dated:
Questionnaire Relative To The Proposed Insurance Of Stallion First Season Infertility
Note to attending Veterinary Surgeon
Insurers recognise and acknowledge that some of the undernoted questions may be difficult
or impossible to answer because of the colt’s temperament or other factors. In such cases
please simply record the words “Not Possible” and, if you consider it helpful or relevant to
potential insurers, state the reason why.
Please provide full details on any answer to the questions below that would reasonably
require qualification. If more space is necessary please us the reverse of this form or attach a
further sheet as appropriate.
Insurers will adjudge acceptance or declinature of the proposed insurance from those
answers you are able to give below.
NAME OF PROPOSED STALLION:
SIRE:
DAM:
1. Scrotum
(i)
Have both testicles descended fully
and are they situated normally? (If
NO please provide details)
(ii)
On inspection,
- is symmetry normal?
- any skin lesions?
(iii)
On palpation,
- is symmetry normal?
- any skin lesions?
2. Testicles
(i)
Are the testicles hard, firm
or soft?
(ii)
Any evidence of fibrosis,
calcification, haematomas,
infection or injury?
(iii)
Dimensions (cms):
A – Approx dimensions of
each testicle
OR if not possible
B – Width of each testicle
Stretched down into scrotum
3. Prepuce
Your comments when
(i)
Penis non-erect:
(ii)
Penis erect:
Height
Left:
Right:
Width
Length
(iii)
On inspection,
- any lesions?
- any discharge?
(iv)
On palpation,
- any lesions?
- any discharge?
4. Penis
Your comments on
(i)
Erect inspection,
- any lesions?
- any discharge?
(ii)
On palpation,
- any swelling?
- any pain?
- any heat?
5. Libido
Was he disinterested?
Interested / enthusiastic?
6. General
(i)
Are the haematology and
serum protein (albumin and
globulin) contents normal?
(ii)
Has the horse been treated with Cimedtidine/Tagamet during the
past twelve months? (This question MUST be answered – please consult with the
owner, trainer and/or attending veterinarian(s) while at racetrack if necessary to
secure this information.)
(iii)
Please provide exact dates of administration, dosage and type of anabolic steroid
given to the horse during the past twelve months. (This question MUST be answered
– please consult with the owner, trainer and/or attending veterinarian(s) while at
racetrack if necessary to secure this information.)
(iv)
Has the horse been treated with Methotrexate? (This question MUST be answered –
please consult with the owner, trainer and/or attending veterinarian(s) while at
racetrack if necessary to secure this information.)
(v)
Has the horse received any other
drugs? If so, for what reason?
(vi)
Has the horse suffered from
a febrile illness during the past
six months?
(vii)
Were any murmurs or arrythmias
detected on auscultation of the
heart? If YES, please describe
their nature.
(viii)
Is the general bodily condition
of the horse reasonable?
(ix)
Does the horse have a
masculine appearance?
(x)
Are there any clinical signs
arising from the examination
indicative of recent or current
disease or abnormal conditions?
7.
Any other observations you may consider as pertinent to assist in insurance
assessment of the proposed stallion’s suitability for first season infertility insurance?
(If none, please write NONE)
Name of Veterinary Surgeon:
Date of Inspection:
Signature of Veterinary Surgeon:
Place of Inspection: