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<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" background="145ef2d3.jpg"> <div> <B><IMG SRC="29522460.jpg" border=0 width="546" height="70" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFFFFF" TEXT="#080000" background="145ef2d3.jpg"> <div> <A HREF="index.htm" TARGET="_top" TITLE=" "><U>Home</U></A></div> <div> <A HREF="about_us.htm" TARGET="_top" TITLE="About Us"><U>About Us</U></A></div> <div> <A HREF="contact_us.htm" TARGET="_top" TITLE="Contact Us "><U>Contact Us  </U></A></div> <div> <A HREF="horse_insurance.htm" TARGET="_top" TITLE="Insurance For Your Horse"><U>Insurance For Your Horse</U></A></div> <div> <A HREF="farm_insurance.htm" TARGET="_top" TITLE="Farm Property Insurance "><U>Farm & Property Insurance  </U></A></div> <div> <A HREF="liability_insurance.htm" TARGET="_top" 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SRC="23c1e2c0.jpg" border=0 width="286" height="44" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <bR> <div> <B>PLEASE COMPLETE THIS FORM FOR A QUOTE</B></div> <div> <B>FOR INSURANCE ON YOUR HORSE</B></div> <bR> <div> <B>ALL RISK MORTALITY & THEFT</B></div> <div> <B>WITH OPTIONAL COVERAGES</B></div> <bR> <div> <B>Immediate Coverage Available</B></div> <div> <B>Please download required forms:</B></div> <bR> <div> <A HREF="http://www.insurehorses.com/Mortality app 2.01.pdf" TARGET="_top" TITLE="http://www.insurehorses.com/Mortality ap"><U><B><IMG SRC="2a9c8300.jpg" border=0 width="200" height="48" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B>  (Signed & Dated)</B></div> <bR> <div> <A HREF="http://www.insurehorses.com/Vet cert.pdf" TARGET="_top" TITLE="http://www.insurehorses.com/Vet cert.pdf"><U><B><IMG SRC="2a04c300.jpg" border=0 width="332" height="48" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B> (Values over $25,000)</B></div> <bR> <div> <A HREF="http://www.insurehorses.com/hlth stmt.pdf" TARGET="_top" TITLE="http://www.insurehorses.com/hlth stmt.pd"><U><B><IMG SRC="2adb4300.jpg" border=0 width="180" height="48" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B>  </B><B> (Values $25,000 or less)</B></div> <bR> <div> <A HREF="justification_of_value.htm" TARGET="_top" TITLE="Justification Of Value"><U><B><IMG SRC="2ae05300.jpg" border=0 width="261" height="48" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <bR> <div> <B>To complete the application requirements,</B></div> <div> <B>Fax required documents to (502) 493-0070</B></div> <bR> <div> <B>Or Mail to:</B></div> <bR> <div> <B>Smith-Embry Insurance Associates, Inc.</B></div> <div> <B>3044 Breckenridge Lane</B></div> <div> <B>Suite LL1</B></div> <div> <B>Louisville, KY  40220-2193</B></div> <bR> <bR> <div> *Required Fields</div> <bR> <div>  <HEAD> <FORM METHOD="POST" ACTION="http://www.insurehorses.com/cgi-bin/formmail.pl"> <INPUT TYPE="hidden" NAME="recipient" VALUE="tamara@insurehorses.com"> <INPUT TYPE="hidden" NAME="All Risk Quote Request" VALUE=" All Risk Quote Request "> <INPUT TYPE="hidden" NAME="redirect" VALUE="http://insurehorses.com/thanks.htm"> <TR> <P><LEFT><TABLE WIDTH="448" BORDER="0" CELLSPACING="5" CELLPADDING="0" HEIGHT="413"> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Your Name:</FONT></TD> <TD WIDTH="58%" BGCOLOR="#F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Your Name" SIZE="30" MAXLENGTH= "25"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Your Farm:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Name of Farm" SIZE= "30" MAXLENGTH="25"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Your Address:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Address" SIZE="30" MAXLENGTH="25"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>City/State/Zip:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="City" SIZE="15" MAXLENGTH="25"> <INPUT TYPE="text" NAME="State" SIZE="3" MAXLENGTH="3"> <INPUT TYPE="text" NAME="Zip" SIZE="8" MAXLENGTH="5"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Home Phone:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Phone Number" SIZE="30" MAXLENGTH="12"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Best time to call:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Best time to call home" SIZE="30" MAXLENGTH="12"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Work Phone:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Work Phone Number" SIZE="30" MAXLENGTH="12"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Best time to call:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Best time to call work" SIZE="30" MAXLENGTH="12"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Fax:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Fax Number" SIZE="30" MAXLENGTH="12"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>E Mail:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="E-Mail" SIZE="60" MAXLENGTH= "55"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Method of Contact</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><select name="Method of Contact"> <option value=""></option> <option value="Email">Email</option> <option value="Postal">Postal</option> <option value="Phone">Phone</option> <option value="Fax">Fax</option></select></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Breed of Horse:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Breed of Horse" SIZE= "30" MAXLENGTH="25"></FONT></TD></TR> <TR> <td valign =top colspan=2><font size=2 face=arial> If Breed Is AQHA, Paint or Appaloosa, we need to have the following Questions Answered. Has the horse been tested for HYPP?</font></i></b></td> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Has the horse been tested for HYPP?</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><select name="Has the horse been tested for HYPP?"> <option value=""></option> <option value="N/A">N/A</option> <option value="Yes">Yes</option> <option value="No">No</option> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial">Results of HYYP Test?</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><select name="Results of HYYP Test?"> <option value="Don't Know">Don't Know</option> <option value="NN">NN</option> <option value="NH">NH</option> <option value="HH">HH</option> <TR> <td valign =top colspan=2><font size=2 face=arial> Quarter horses, Paints and Appaloosas are required to be tested. Certainly, if a progeny of the Impressive lineage; if sire or dam is NH or HH; or if animal’s registration papers indicate NH or HH for HYPP. Eligibility for insurance depends on HYPP status.</font></td> <TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Name Of Horse:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Name Of Horse" SIZE= "40" MAXLENGTH="35"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Sex Of Horse:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Sex of Horse" SIZE="30" MAXLENGTH="25"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Age Of Horse:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Age Of Horse" SIZE= "30" MAXLENGTH="25"></FONT></TD></TR> <TR> <TD BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Use of Horse:</FONT></TD> <TD BGCOLOR="F4EED3"><P><LEFT><FONT SIZE=-1 FACE="Arial"> <SELECT NAME="Use of Horse"> <OPTION VALUE="Nothing Selected" SELECTED>Select <OPTION VALUE="Breeding">Breeding <OPTION VALUE="Foal/Weanling">Foal/Weanling (Req D.O.B.) <OPTION VALUE="Yearling">Yearling <OPTION VALUE="Pleasure ">Pleasure <OPTION VALUE="Show Halter ">Show Halter <OPTION VALUE="Show Western Pleasure ">Show Western Pleasure <OPTION VALUE="Show English Pleasure ">Show English Pleasure <OPTION VALUE="Show Country Pleasure ">Show Country Pleasure <OPTION VALUE="Show Hunter Under Saddle ">Show Hunter Under Saddle <OPTION VALUE="Dressage (no jumping activities) ">Dressage (no jumping activities) <OPTION VALUE="Driving ">Driving <OPTION VALUE="Show Hunter ">Show Hunter <OPTION VALUE="Hunter Jumper (under 4,6') ">HunterJumper (under 4,6") <OPTION VALUE="Show Jumper ">Show Jumper <OPTION VALUE="Eventing (Training Level & below ">Eventing (Training Level & below) <OPTION VALUE="Eventing (Preliminary Level & up ">Eventing (Preliminary Level & up) <OPTION VALUE="Flatracing ">Flatracing <OPTION VALUE="Field Hunter">Field Hunter <OPTION VALUE="Fox Hunter ">Fox Hunter <OPTION VALUE="Endurance/Distance">Endurance/Distance <OPTION VALUE="Cutting ">Cutting <OPTION VALUE="Team Penning ">Team Penning <OPTION VALUE="Reining">Reining <OPTION VALUE="Roping ">Roping <OPTION VALUE="Barrel Racing">Barrel Racing </SELECT> </FONT></LEFT></TD></TR> <TR> <TD BGCOLOR="F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"></font>Other Uses Of Horse:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Other uses Of Horse" SIZE= "30" MAXLENGTH="25"></FONT></TD></TR> <TR> <TD WIDTH="42%" BGCOLOR="#F4EED3" HEIGHT="32"><FONT SIZE=-1 FACE="Arial"><font color="red">*</font>Value Of Horse:</FONT></TD> <TD BGCOLOR="F4EED3" ALIGN="LEFT"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="text" NAME="Value Of Horse" SIZE="30" MAXLENGTH="25"></FONT></TD></TR> </TABLE> <TR> <BR> <B><FONT SIZE=-1 FACE="Arial">QUOTE ADDITIONAL COVERAGE FOR THIS HORSE:<BR> </FONT></B><TABLE WIDTH="448" BORDER="0" CELLSPACING="5" CELLPADDING="0" HEIGHT="471"> <TR> <TD COLSPAN="2" BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="checkbox" NAME="QUOTE ADDITIONAL COVERAGE FOR THIS HORSE" VALUE="12-Month Guarantee Extension - Mortality">12-Month Guarantee Extension - Mortality<br> <TR> <TR> <TD COLSPAN="2" BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="checkbox" NAME="QUOTE ADDITIONAL COVERAGE FOR THIS HORSE" VALUE="Emergency Colic Surgery Extension">Emergency Colic Surgery Extension<br> <TR> <TD COLSPAN="2" BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="checkbox" NAME="QUOTE ADDITIONAL COVERAGE FOR THIS HORSE" VALUE="Major Medical Coverage"> Major Medical/Surgical (Age restrictions apply) <FONT SIZE=-1 FACE="Arial">Quote Limit</FONT> <SELECT NAME="Major Medical Coverage Quote Limit"> <OPTION VALUE="Nothing Selected" SELECTED>Select <OPTION VALUE="$5000">$5000 <OPTION VALUE="$7500">$7500 <OPTION VALUE="$10,000">$10,000 </SELECT> </FONT></TD></TR> <TR> <TD COLSPAN="2" BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="checkbox" NAME="Quote additional coverage for this horse" VALUE="Surgical Only Coverage">Surgical Only Coverage (Age restrictions apply)<br> <FONT SIZE=-1 FACE="Arial">Quote Limit</FONT> <SELECT NAME="Surgical Only Coverage Quote Limit"> <OPTION VALUE="Nothing Selected" SELECTED>Select <OPTION VALUE="$5000">$5000 </SELECT> </FONT></TD></TR> <TR> <TD COLSPAN="2" BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="checkbox" NAME="QUOTE ADDITIONAL COVERAGE FOR THIS HORSE" VALUE="Stallion Accident, Sickness, Disease Infertility (not available first year stallions)">Stallion Accident, Sickness, Disease Infertility (not available first year stallions) <TR> <TD COLSPAN="2" BGCOLOR="F4EED3"><FONT SIZE=-1 FACE="Arial"><INPUT TYPE="checkbox" NAME="Quote additional coverage for this horse" VALUE="Loss of Use (Requires Major Medical & Surgical Coverage) Loss Of Use Coverage is available ONLY for Show Use with the exception of Halter, Western Pleasure, Eventing, Field Hunters, Barrel Racing Endurance/Distance, Cutting, Team Penning, Reining and Roping.”"> Loss of Use (Requires Major Medical & Surgical Coverage. Loss Of Use Coverage is available ONLY for Show Use with the exception of Halter, Western Pleasure, Eventing, Field Hunters, Barrel Racing, Endurance/Distance, Cutting, Team Penning, Reining and Roping.”)</FONT><br> <FONT SIZE=-1 FACE="Arial">Loss of Use</FONT> <SELECT NAME="Loss of Use"> <OPTION VALUE="Nothing Selected" SELECTED>Select <OPTION VALUE="External Injury Loss Of Use">External Injury Loss Of use <OPTION VALUE="Full Loss Of Use">Full Loss Of Use </SELECT> </TD></TR> <TR> <TR> <td valign =top colspan=2><font size=2 face=arial> To Complete Insurance Process for an Immediate Binder (An insurance binder provides temporary coverage while the original application, other required forms, and premium are sent to us through the mail.) Fax completed forms to (502) 493-0070 or Mail to: Smith-Embry Insurance Associates, 3044 Breckenridge Lane; Suite LL1; Louisville, KY 40220-2193 Requirements:Completed, Signed, Dated Application. Veterinary Certificate (values over $25,000). Health Statement (values $25,000 or less)’ Justification of Value & Premium Payment</font></td> <TR> <tr> <TD COLSPAN="2" BGCOLOR="F4EED3" ALIGN="LEFT"><b><i><font face="helvetica, arial" size="-1">Submit a new form on each horse for which you require a quote.</i></b></font></td> </tr>  <TR> <TD BGCOLOR="F4EED3" WIDTH="44%" HEIGHT="81"><FONT SIZE=-1 FACE="Arial">Comments or Questions:</FONT></TD> <TD BGCOLOR="F4EED3" WIDTH="56%"><P><LEFT><FONT SIZE=-1><TEXTAREA NAME="Comments/Questions" ROWS="3" COLS= "29" wrap="soft" ></TEXTAREA></FONT></LEFT></TD></TR> <TR> <TD COLSPAN="2" ALIGN="LEFT"> <INPUT NAME="name" TYPE="submit" VALUE="Submit Quote"> <INPUT NAME="name" TYPE="reset" VALUE="Reset Form"> <br><br><div align="LEFT"><font face="helvetica, arial" color="red" size="-1">* Required Fields</div></TD></TR> </TABLE>  </div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <A HREF="privacy_policy.htm" TARGET="_top" TITLE="Privacy Policy"><U>  Privacy Policy </U></A>    </div> </td> </tr></table></body>