VETERINARY CERTIFICATE OF EXAMINATION FOR MORTALITY INSURANCE

Print - then Fax or Mail to Jame Secondino
20860 Clinton Rd. Paris, IL 61944
Phone - 765-832-2697 - Fax 765-832-9185

VETERINARY CERTIFICATE OF EXAMINATION FOR MORTALITY INSURANCE

Horses being examined for insurance should be moved about outside the stall to demonstrate soundness of limb and freedom of movement. Careful observation and inquiry should be made as to housing conditions and the presence of contagious disease. This certificate should be completed by the examining Veterinarian to the best of his ability as a licensed Veterinarian. The completed certificate should be forwarded without delay.

I, do hereby certify that I am a graduate veterinarian holding a current license as such to practice in the

State of and that I have this day examined:

Name _______________________________________________________________________________________

(use back of page for more than one horse) Age Color Sex Breed

Sire _______________________________________________ Dam _____________________________________

Markings or tattoo number _______________________________________________________________________

____________________________________________________________________________________________

Owned by ___________________________________________________________________________________________

Name Address

Yes No	Yes No
Pulse and respiration normal? ___ ___	History or evidence of nerving? ___ ___
Temperature normal? ___ ___	Has horse been castrated? ___ ___
Eyes clinically normal? ___ ___	Has any surgery been performed on the horse? ___ ___
Heart auscufated? ___ ___	If mare, is she reported in foal? ___ ___
History or evidence of bleeder? ___ ___	If male, are both testicles evident? ___ ___

If any surgery has been performed, describe type of surgery ____________________________________________
__________________________________________________________________________________________

Is there any likelihood of future danger to life or limb as a result of such surgery? ______________________________

____________________________________________________________________________________________

Any lameness or faulty conformation or other abnormal conditions? ________________________________________

____________________________________________________________________________________________

Is the stabling adequate? ________________________________________________________________________________

In your opinion or to your knowledge, are there any medical facts that should be brought to the attention of the company?

____________________________________________________________________________________________

Is there evidence of vices or objectionable habits? ____________________________________________________________________________________________

Has official E.LA Test been run?_____________ Date?________ Lab. No.___________ Result ________________________

Except as noted above, I hereby certify that to the best of my knowledge and belief the horse is normal in every other respect.

Remarks:_____________________________________________________________________________________

____________________________________________________________________________________________

Signed ___________________________________________
Veterinarian

Date of examination _______________________ Address ___________________________________________

Print - then Fax or Mail to Jame Secondino
20860 Clinton Rd. Paris, IL 61944
Phone - 765-832-2697 - Fax 765-832-9185