Fillable California Race Horse Owners Liability (Abram Interstate Insurance)

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California Race Horse Owners Liability (Abram Interstate Insurance)

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The California Race Horse Owners Liability (Abram Interstate Insurance) form is 2 pages long and contains:

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  • 3 check-boxes
  • 183 other fields

Country of origin: US
File type: PDF

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Agency Phone # () -
Producer
New Business Quote Issue
Renewal of #
Agency Bil
l
A
Semi-
A
Q 10 payment
s
Direct Bill to Applican
t
A
Monthl
y
Mulitiple
() -
A. Are the horses scheduled above stabled on premise of a farm owned or leased by you? Yes No
B.
C. Is horse leased? Yes No
D. Yes No
E. Yes No
Page 1 of 2
Customer No.
Producer No
4
5
Explain "Yes" answer and provide copy of lease agreement
Explain "Yes" answer
Does your trainer carry liability and workers' compensation insurance?
If "Yes" to A, describe all facilities and uses including acreage. Is facility covered by farm or homeowner policy? Provide
name of carrier, policy term and limits of liability. S
tall rental by you at a boarding facility does not constitute leased premises.
(Note: This is not a Binder. Incomplete or unsigned applications will be returned for completion.)
Breed Use
Name of Horse
Partnership LLC
Do you or your employees have any involvement with training or breeding of horses?
Company Use Only
Coverage applies only to injury/damage
caused by named horses.
No
p
remise covera
g
e afforded
.
Agency's Name and address (Include Zip Code)
Other
ZipSt
Owner/Operator Absentee Owner
IF YOU HAVE ANSWERED 'YES' TO 'C', ABOVE, THE RATES INDICATED ON PAGE 2 DO NOT APPLY. PLEASE
SUBMIT THE PROPER APPLICATION FOR QUOTE.
F. 8935 Apr-04
Manager
Transaction
Applicant is
Corporation
Direct Bill installment plans have fees.
Quote Desired ByEffective Date
to
City
Agency installments require premium to be $1,000 or more plus there are installment
Co
Insured's Phone Number WWW:
City
California Race Horse Owners Liability
Are certificates provided?
Yes No
% of Ownership
St
Applicant - Name and address ( include County and Zip Code)
Zip
1
2
3
Submit
RESET
Submit
RESET
Code 88281
Premium
Page 2 of 2
Additional insured
form required.
California Race Horse Owners Liability - Continued
Name and address
of boarding facility
Explain any losses
No
# of
Claims
If 'Yes', give reason:
Have you been cancelled or non-renewed in the past 3 years?
A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
Any person who knowingly and with intent to defraud any insurance company or other person files a satement 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.
Any person who knowingly and with intent to injure or defraud any insurer files any application or claim containing any
false, incomplete or misleading information shall, upon conviction, be subject to immprisonment for up to 1 year for a
misdemeanor conviction or up to 10 years for a felony conviction and payment of a fine of up to $5,000,000.
Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim containin
g
any false, incomplete or misleading information is guilty of a felony.
Michigan:
Kentucky:
Delaware:
INSURANCE FRAUD WARNING - APPLICANT TO INITIAL ALL APPLICABLE STATES
Pennsylvania:
Yes
OCCURRENCE/AGGREGATE
LIMITS OF INSURANCE
$300,000 / $600,000
Minnesota:
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any
false, incomplete or misleading informatin shall, upon conviction, be subject to imprisonment for up to 7 years and
payment of a fine of up to $15,000.
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Comments
All Insurance applications and claim forms except auto:
Ohio:
Oklahoma:
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Any person who knowingly and with intent to defraud any insurance company or other 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 shall also
be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such
Policy #
$750
Name of Company
$1,000
Premium
Subject to State
Charge
Minimum Premiums are Fully Earned
$1,000,000 / $2,000,000
$500,000 / $1,000,0000
$1,250
Coverage
Dates
Loss Amount
The above statements given are true and accurate. This includes the limits of insurance and loss history as shown. I have not
willfull
y
concealed or misrepresented an
y
material, fact or circumstance concernin
g
this application
.
Agents Signature:
DateApplicant's Signature:
Date
New York:
$750
F.8934 Apr-04
Experience - 4 Years
* Fully Earned premium means no return premium for mid-term cancellations.
** >15 Refer to Company
CHECK ONLY
ONE
State Tax /
Surcharge
Refer to Co
Final Premium
By Company
$350
$500
$750
$500
$1,000
Number of Horses
1-5 6-10 11-15 **
Submit
RESET
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California Race Horse Owners Liability (Abram Interstate Insurance)

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Completed 10 July 2021

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