TSW MANAGEMENT SERVICES INC.
APPLICATION FOR HORSE MORTALITY INSURANCE
(1) Name of Insured:
_________________________________
Email ______________________________________
(2) Address:
____________________________________ City ________________
Postal: ______________
(3) Residence Phone: ____________________ Business Phone: ______________________ Fax: _________________
(4) Loss Payable or Mortgagee (if applicable) & Address: ____________________________________________________
(5) Horses Located at: _______________________ (5) Name/phone of farm manager:____________________________
(6) CEF # __________________ and / or Provincial Membership # _________________
(7) Horses to be insured:
NAME
CTHS MEMBER: YES / NO
For Sex, please use: M for Mare, S for Stallion, G for Gelding, F for Filly, C for Colt
YEAR SEX
BREED
USE
PURCHASE PRICE
AMOUNT OF
BORN
OR STUD FEE
INSURANCE
(8) Date of acquisition: ______________ If amount of insurance exceeds purchase price, please justify: _______________
________________________________________________________________________________________________
(9) Has any Horse(s) owned by you died n the past 36 months? __________ If yes, state cause and if insured, name of Insurer and
broker._________________________________________________________________________________
(10) Has any Insurance Company ever cancelled or refused to insure any horses of which you have or had an insurable interest?
______
If yes, give details: __________________________________________________________________
(11) State nature of any illness or injury to above animal(s) in past 36 months: _____________________________________
(12) Has any vet or insurance company declined insurance on this animal(s)? ___________________________
(13) Was this animal previously insured or do you or your partners presently insure it? _____ If yes, indicate expiry date of policy,
amount of insurance, company and broker name: ___________________________________________________
(14) Name and telephone number of your usual veterinarian: ___________________________________________________
In regards to the above personal information pertaining to myself and my horse I give BFL Canada permission to gather and
communicate with necessary individuals (eg. Veterinarian, Trainer, Underwriters) for insurance purposes._________
PREMIUM CALCULATION SUMMARY
(Please Initial)
COVERAGE TYPE
All Risk Mortality** ______________ x ________________
(horse value)
(mortality rate**)
OR
Specified Perils
______________ x ________1%______
(horse value)
(specified perils rate)
Surgical Insurance:
Yes
$2,500 Limit

$5,000 Limit

$7,500 Limit

OR
Major Medical Coverage (not available for racers)
$5,000 Limit

$7,500 Limit

Death Claim Reimbursement :
$1,000 Limit

Tack Coverage:
Additional Tack Coverage: _____________ x ______1%_____
(value of tack)
(tack rate)
Other Coverages:
Liability $ 1,000,000 Limit

PREMIUM
_____________
No



______________



$ 500 INCL. Yes  No 
______________
$1500 INCL. Yes  No 
______________

______________
______________
______________ x ___0.5%______
(horse value)
NOTE: MINIMUM POLICY PREMIUM IS $150
TOTAL:
COVERAGE CANNOT BE BOUND UNTIL THIS APPLICATION AND A COMPLETED SATISFACTORY VETERINARIAN
CERTIFICATE ARE RECEIVED AT THE BROKER’S OFFICE. THE VETERINARIAN CERTIFICATE MUST BE COMPLETED WITH
30 DAYS OF RECEIPT.
Guaranteed Renewal
STATEMENT OF APPLICANT: I understand that this application shall be the basis of the policy of insurance if issued. Any
material misrepresentation or omission in this application will render any such policy null and void. I further understand that
no Insurance shall take effect unless this application is accepted together with a clean veterinary certificate and a that policy
issued. In the event a policy is issued, I agree to report by phone any illness, injury, disease or death of any insured animal
immediately.
DATE: ________________________ Signature of Applicant: _______________________________________________