Substantiation for Insurance Values

Insured: ________________________________________________________________

Address: ________________________________________________________________

AMOUNTS OTHER THAN THE PURCHASE PRICE ARE SUBJECT TO ACCEPTANCE
BY THE COMPANY FOR THE CONSIDERATION OF INCREASE AND/OR STATED
VALUES.  Please indicate below each animal’s records (if any) of Show (class points), Racing
(wins earned), Sires (stallion), and Produce (mares).  Also, include details of prize winnings, stud
fees, value of progeny (full brother-sister) sold-raced-shown, additional cash investments, and
other pertinent date relating to value (attach additional sheets as required):

Name                     Information

(1)______________________________________________________________________

________________________________________________________________________

(2)______________________________________________________________________

________________________________________________________________________

(3)______________________________________________________________________

________________________________________________________________________

____________________________________                               ____________________

Signature                                                                                         Date