TRAILER OWNER INFORMATION
Name
Member of US Rider? Yes No
If so, what is your member number?
Area Code and Phone Number (Format 222-222-2222)
Your Email Address (Please Double Check)
Mailing Address (Street)
Mailing Address 2 (Suite, Apartment)
City
State
Zip Code
County
Primary Driver's Date of Birth (Format mm/dd/yyyy)
Primary Driver's License # and State of Issue DL# State of Issue
Desired Effective Date of Coverage (Format mm/dd/yyyy)
Has any policy or coverage been
declined, cancelled, or non-renewed
during the prior 3 years?
No Yes
During the last 5 years,
has anyone named above been convicted
of any degree of the crime of arson
No Yes
Has anyone named above had a horse
trailer claim during the
prior 3 years? If Yes, describe briefly including the amount of loss.
No Yes
INFORMATION ABOUT YOUR TRAILER
Year
Make
Model
VIN Number
Trailer Value. Please enter the value of the trailer based on its age. If under 5 years old - the purchase price. If over 5 years old - the current value.
Trailer Value $
Optional Tack Coverage. Valid amounts are $5,000, $10,000 or any amount over $10,000
Optional Tack Coverage $
If the trailer is financed, who is the loss payee (The Lender)?
Lender's Name
Lender's Address
Lender's Address 2
Lender's City
Lender's State
Lender's Zip Code
Your Annual Premium $
Special Instructions
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES. Insurance benefits may also be denied.

BY CLICKING THE "Submit Application" BUTTON BELOW, I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE READ THE FRAUD STATEMENT ABOVE.