If emergency surgery is required, immediate notice is required.
All requests will be denied if not submitted within five days from the date of the incident*.
Please check one
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?
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:
Is this an FEI class ?
Where is the horse being stabled?
If “offsite,” please provide stabling location and address:
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.
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).
1035 State Rd 7 Suite 215
Wellington, Florida 33414
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