Fillable American Bankers COMMERCIAL EQUINE LIABILITY RENEWAL QUESTIONNAIRE (Risk Placement Services, Inc.)

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American Bankers COMMERCIAL EQUINE LIABILITY RENEWAL QUESTIONNAIRE (Risk Placement Services, Inc.)

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Designed By: JB
A8210.DOC-0401 Page 1
American Bankers
Insurance Company of Florida
222 South 15
TH
St, Suite 600S
Omaha, NE 68102
INSURED / DBA AGENT
PHONE NUMBER / E-MAIL ADDRESS PHONE NUMBER / E-MAIL ADDRESS
POLICY NUMBER EXPIRATION DATE AGENCY CODE
COMPLETE ALL OF THE FOLLOWING QUESTIONS THAT ARE APPLICABLE. WRITE NONE OR 0 IF NO EXPOSURE. DO NOT LEAVE
SPACES BLANK. ALL OPERATIONS MUST BE DECLARED. ATTACH A SEPARATE PAGE IF MORE SPACE IS NEEDED.
SUMMARY – AT PEAK SEASON, ACCOUNT FOR EACH ANIMAL BELOW ONLY ONCE BASED ON PRIMARY USE.
Horses Owned/Leased/Used by Insured: Number
1a. Owned horses used for instruction...................................
b. Boarded horses used for instruction to others.................
2. Show and/or pleasure.......................................................
3. Racing and/or training to race..........................................
4. Breeding (Mares , Stallions )........................
5. Foals/weanlings ................................................................
6. Retired and/or lay-ups ......................................................
7. For sale (Breed )
8. Other (Describe: )
Horses Non-Owned by Insured: Number
1. Boarding/pasturing............................................................
2. Show training ...................................................................
3. Racing and/or training to race..........................................
4. Breeding (Mares , Stallions )........................
5. Foals/weanlings ................................................................
6. Retired and/or lay-ups .....................................................
7. Consignment for sale (Breed ) ...............................
8. Other (Describe: ) ..................................................
All Owned Horses Must be Declared
Total (Lines 1-8)
Total (Lines 1-8)
9. Number of carts, buggies, carriages, etc. ........................
Describe Use:
9. Total number of stalls on your premises .........................
10. What is the maximum number of horses, owned and
non-owned that can be kept on your premises? .............
RIDING INSTRUCTION – CLINICS: (Breakdown Annual Gross Receipts for the following categories.)
1. Handicapped Program: Number of lessons/week ...........
2. Maximum number of school horses available..................
3. Receipts for instruction on school horses: ......................$
Average number of lessons per week..............................
4. Receipts for attending off-premise shows
with students on school horses ........................................$
5. Number of clinic days for non-students............................
Gross receipts.......................................................................$
Maximum number of school horses used at one time.........
Receipts for instruction to students on their own horses..........$
Average number of lessons per week..................................
*Receipts for day camp activities .........................................$
Total number of campers......................................................
Provide clinic dates: .................................................................
6. Receipts earned by independent instructors: On school horses $ On student owned horses $
7. Do you have any employees?_____________________________________________________________
8. Provide name and address of Independent Instructor(s) to be covered on this policy.
Name Address Years Experience Release
Must be 18 years of age or older.) Advise number of years experience for each. If more space is needed, attach a separate page. Attach a copy of
their release if not on file with the company.
*Additional information on camping activities may be requested by the Company.
COMMERCIAL EQUINE LIABILITY
RENEWAL QUESTIONNAIRE
A8210F.DOC-0401 Page 2
HORSE SHOWS AND OTHER MISCELLANEOUS INFORMATION
(Attach a separate page if more space is needed)
Prior notification is required for all public event days.
1. Number of public event / show days held on premise Number of participants per show
Provide dates for events:
2. If AHSA, provide competition number Dates when spectators exceed 500 per day:
3. If you are required to provide a certificate as proof of insurance, provide names and complete addresses of each.
4. If you request coverage for an additional insured, please submit name, complete address, and insurable interest for company
approval.
5. Number of horses sold annually: Gross receipts from Tack Shop: $
6. Are you obtaining release agreement / waivers from students and boarders? Yes No
If applicable, do you post state equine liability warning signs? Yes No
Do you hand out or post barn and safety rules? Yes No Are No Smoking signs posted? Yes No
7. Do you provide or conduct any of the following activities: pony rides, pony parties, hay, sleigh or carriage rides; rental of horses to
the public or pack trips? Yes No If yes, provide details.
8. Do you own or use recreational vehicles in your stable operations? Yes No If yes, describe and explain how they are used.
DESCRIBE FULLY ANY OTHER EVENTS / ACTIVITIES CONDUCTED. ALL OPERATIONS MUST BE DECLARED.
If there are any material changes in your stable operations during the policy year, please notify your agent at once.
The undersigned hereby applies for insurance coverage as set forth in the application and affirms that the statements and
representations made are to the best of his/her knowledge true.
INSURED’S SIGNATURE
x
DATE
AGENT’S SIGNATURE
x
DATE
NOTE: I am interested in the availability of increased limits for the coverage checked below:
$10,000 Medical Payments to Others
$100,000 Fire Legal Liability
Increase Liability Limit to $500,000 $1,000,000
If you have declined coverage for the Legal Liability on non-owned horses in your care, custody or control, your signature rejecting
coverage is required.
SIGNATURE
x
IMPORTANT – ORIGINAL MUST BE RETURNED
INSURED’S SIGNATURE IS NEEDED TO PROVIDE A FIRM QUOTE AND IN ORDER TO BIND COVERAGE
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American Bankers COMMERCIAL EQUINE LIABILITY RENEWAL QUESTIONNAIRE (Risk Placement Services, Inc.)

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Completed 30 July 2020

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