Show+ | Protect Your Passion™

Incident Form

Owner Name

Rider Name

Incident Type

Please check one

Contact Email

Confirm Email

Contact Phone Number

Permanent Mailing Address

Temporary Mailing Address

Horse Name

Horse Name in Barn

Name of your Medical Provider

Provider's Contact Phone Number


Back Number

Show Name

Person Completing the Report

Relation to Reported Horse/Rider

Has the owner purchased commercial insurance for the affected horse ?

Was the animal euthanized?

Has the owner purchased commercial insurance for the affected rider ?

Did the rider die ?

If Yes, Was the horse’s death caused by injuries incurred during the show/festival?

If Yes, Was the rider’s death caused by injuries incurred during the show/festival?

Date of Incident

Time of Incident

AM or PM

Describe the Nature of the Incident

Did the horse get hurt during or immediately after a show/class?

Did the rider get hurt during or immediately after a show/class?

Were the horse/rider registered for a class the week of the incident?

If “yes,” please provide the specific class number and date regarding which show/class:

Class Number

Class Date

Where is the horse being stabled?

If “offsite,” please provide stabling location and address:

Stabling Location

Stabling Address

If the incident is approved, who should the benefit check be made payable to?

If the incident is approved, where should the benefit check be mailed?

Street Adress

Street Address

City

State

Zip


By typing your name in the format indicated below in the signature block (your name with the /s/ before it), you confirm your intent to sign electronically. You agree that you are agreeing to the terms of this document and affixing an electronic signature. Such electronic signature will have the same validity, enforceability and admissibility as a wet ink signature.

You have the ability to opt out of an electronic signature. You may download, complete, sign and return this form to us via fax at 561-493-3313. Please be advised that requiring the transaction to be performed via hard copy could delay matters. We have the ability to promptly provide a copy of the electronically signed document.

Signature (your name with the /s/ before it)

Date

By clicking "Send" under penalty of perjury, you swear and affirm that the foregoing facts are true and correct. Should any of the information that you submit be false, you understand any request for reimbursement may be denied.



(*exceptions may be made only in extreme, extenuating circumstances, like an act of God or acute, personal hardship that interfere with the ability to submit an incident form).

Contact ShowPlus

Monday-Friday

9:00am-9:00pm EST

Saturday-Sunday

12:00pm-5:00pm EST

(800) 881-6577

TheTeam@ShowPlus.com

1035 State Rd 7 Suite 215
Wellington, Florida 33414

Incident Successfully Submitted


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