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Report an Incident

If emergency surgery is required, immediate notice is required.
All requests will be denied if not submitted within days from the date of the incident*.

Incident Form

Event Name

Owner Name

Rider Name

Incident Type

Please check one

Professional Amateur Junior

Groom Name

Groom Address

Groom City

Groom State

Groom Zip

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

Person Completing the Report

Relation to Reported Horse/Rider

Has the owner purchased commercial insurance for the affected horse ?

Yes No

Did the animal die?

Yes No

Was the animal euthanized?

Yes No

Has the owner purchased commercial insurance for the affected rider ?

Yes No

Did the groom die?

Yes No

Did the rider die ?

Yes No

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

Yes No

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

Yes No

Date of Incident

Time of Incident

AM or PM

Location Of Incident

Was the Horse/Rider registered to go at this time ?

Yes No

Provide detailed information of incident

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

Yes No

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

Yes No

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

Yes No

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

Class Number

Class Date

Is this an FEI class ?

Yes No

Where is the horse being stabled?

Offsite On Showgrounds

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 INSERTING YOUR NAME IN THE SIGNATURE BLOCK BELOW (YOUR NAME WITH THE /S/ BEFORE IT), YOU CONFIRM YOUR INTENT TO SIGN ELECTRONICALLY. YOU HEREBY VERIFY THAT YOU ARE AGREEING AND CONSENTING TO THE TERMS OF THIS DOCUMENT, ATTESTING AS TO ITS TRUTH AND VERACITY, AND AFFIXING AN ELECTRONIC SIGNATURE BY WHICH YOU INTEND TO BE BOUND.

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. BY SIGNING THE SIGNATURE BLOCK BELOW, YOU HEREBY VERIFY THAT YOU ARE AGREEING AND CONSENTING TO THE TERMS OF THIS DOCUMENT, ATTESTING AS TO ITS TRUTH AND VERACITY.

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.

By clicking send, you understand and agree that all incident reports have to be submitted within days of the incident occurring.

(*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

3260 Fairlane Farms Rd Suite 7
Wellington, Florida 33414

Incident Successfully Submitted