ShowPlus | Protect Your Passion®

Clinic Incident Report

Owner Name

Rider Name

Contact Email

Confirm Email

Contact Phone Number (Include Country Code)

Permanent Mailing Address

Temporary Mailing Address

Horse Name

Horse Name in Barn (If different than show name)

Name of your Provider (Vet, Doctor, or Hospital)

Incident Type

If this report is related to a Rider, please select one

Incident Information

Show Name (and Show Week)

Name Incident Filer

Relation to reported Horse/Rider (example, Barn Manager)

Has the owner purchased commercial insurance for the affected horse/rider ?

Yes No

Did the animal die?

Yes No

Was the animal euthanized?

Yes No

Did the rider die ?

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

Describe The Nature Of The Incident

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

Yes No

Was the rider or horse registered for a show/class/ride the day of the incident ?

Yes No

Location of Incident (Jumping, Dressage, Cross Country, Other)

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 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.

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By (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 Five (5) 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).

Report An Incident

Clinic Incident Report

Owner Name

Rider Name

Contact Email

Confirm Email

Contact Phone Number (Include Country Code)

Permanent Mailing Address

Temporary Mailing Address

Horse Name

Horse Name in Barn (If different than show name)

Name of your Provider (Vet, Doctor, or Hospital)

Incident Type

If this report is related to a Rider, please select one

Incident Information

Show Name (and Show Week)

Name Incident Filer

Relation to reported Horse/Rider (example, Barn Manager)

Date Of Incident

Time Of Incident

AM or PM

Describe The Nature Of The Incident

Location of Incident (Jumping, Dressage, Cross Country, Other)

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 Address

Street Address

City

State

Zip

By (your name with the /s/ before it)

Date

Incident Successfully Submitted

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