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 ?

Did the animal die?

Was the animal euthanized?

Did the rider die ?

If Yes, Was the rider’s death caused by injuries incurred during the show/festival/schooling ?

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?

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

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Date

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(*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).

Incident Successfully Submitted