Fillable Commercial Equine Liability & Care, Custody & Control (Abram Interstate Insurance)

Fill Online, Printable, Fillable, Blank Commercial Equine Liability & Care, Custody & Control (Abram Interstate Insurance) Form

Use Fill to complete blank online ABRAM INTERSTATE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Commercial Equine Liability & Care, Custody & Control (Abram Interstate Insurance)

On average this form takes 151 minutes to complete

The Commercial Equine Liability & Care, Custody & Control (Abram Interstate Insurance) form is 7 pages long and contains:

  • 0 signatures
  • 286 check-boxes
  • 470 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Abram Interstate Insurance forms online.

BROWSE ABRAM INTERSTATE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
App-Commercial Equine Liability 8-11-09 Page 1 of 7
Commercial Equine Liability &
Care, Custody & Control Application
P.O. Box 2009, Glen Allen, VA 23058-2009 • Phone: (800) 262-7535 • Fax: (804) 527-7784
Website: www.horseinsurance.com Email: agapplications@markelcorp.com
This coverage is intended to cover liability arising out of the applicant’s commercial and/or personal horse
operation only. No products liability.
NOTE: Coverage cannot be bound until the Company approves your completed application. The Company’s receipt
of premium does not bind coverage until a written quote has been issued.
Applicant: ________________________________
Business Name: ____________________________
Mailing Address: ___________________________
City:________________
County: _____________
State: ________ Zip Code:_____________
Phone #: (__)_________ Fax #: (__)___________
Contact Person: ________ Contact Phone #:_______
Email: ______________ Web site: ____________
Broker Name: _____________ Broker Number: _____
Company Name: ____________________________
Mailing Address: _____________________________
City: State: ____ Zip Code:______
Phone #: (___) ________ Fax #: (___) _________
Email Address: ______________________________
Section 1 - Applicant Information Desired Effective Date: ___________________________
1. a. Type of Ownership: Corporation Individual∗ Joint Venture Limited Liability Company
Trust Organization Partnership None
b. ∗If applicant is multiple individual names, what is the relationship of applicant(s):
Husband / Wife;
Parent / Child; Siblings; Other:________________________________________________
c. If ownership is not an individual: i. Which entity owns: premises- _________________ horses- _____________
ii. Which entity conducts horse operation: __________________
2. Names of corporate partners/officers for each entity: ____________________________________________________
3. Applicant is a member of:
AHA; AQHA; APHA; ARIA; NRCHA; NRHA; USDF; USEF; USHJA;
Other:__________ None
4. Choose One
$ 300,000 occurrence / $ 900,000 aggregate - $350 Min. Earned Premium($400-NY; $425-CA,FL & WA)
Limit of Liability:
$ 500,000 occurrence / $1,500,000 aggregate - $450 Min. Earned Premium($550-NY; $575-CA, FL & WA)
$1,000,000 occurrence / $3,000,000 aggregate - $550 Min. Earned Premium
($700-NY; $695-CA; $725-FL & WA)
5. Location of Actual Operation(s) (For additional locations, provide on an additional page)
Location
Including Street, County, City, State & Zip Code
# of
Acres
# of
Years at
Location
Responding
Fire District
Name
Feet from
Fire
Hydrant
Miles
from Fire
Dept.
Check
One:
a.
Own Lease
Rent From Others
b.
Own Lease
Rent From Others
Section 2 - Prior Three Year Property & Liability Insurance Information
Must be completed in full in order to receive a quote. Including homeowners, renters and business owners’ policies.
Company Effective Dates Premium No. of Claims Amount Paid
1. a. Has the applicant ever been canceled or refused coverage in the last 5 years?
(Not applicable in Missouri.) Yes No
b. If yes, please explain: __________________________________________________________________________
2. Explain losses/incidents within the past 5 years with dates & details of loss, including amount paid, on separate paper. None
3 Has the applicant ever filed for bankruptcy or had a foreclosure? Yes No Explain:________________________
App-Commercial Equine Liability 8-11-09 Page 2 of 7
Section 3 - Equine Operations
1. All operations must be declared. Check all that apply.
Operation(s):
Boarding/Breeding Horse Sales Pleasure Rodeo∗
Day or Overnight Camp∗ Horse Shows Pony Rides∗ Exotic Animals
Trail/Endurance Rides∗ Llamas /Alpaca Racing NARHA Facility
Training Race/Show Hay/Sleigh Rides Riding Instruction/Clinics
Other: ______________________________________
(
∗
Must complete supplements. Supplements can be downloaded from our website – www.horseinsurance.com)
2. Estimated gross income from equine operation: $
None
3. a. Number of years in this type of operation: _____
b. Describe applicant’s experience in this operation:_____________________
c. Does the applicant live on the premises?
Yes No If no, how often does the applicant visit:________
d. Is there a full-time
caretaker manager? Yes No Are they an: employee or independent?
4. Describe applicant’s experience with horses: _______________________________________________________
5. Do additional insureds need to be added?
Yes No
Insurable Interest:
Owner of Premises Government Entity Other: ___________________________
Name: ____________________________________ Address: _______________________________________
Section 4 - Summary of Horses
Count each horse only once, based on its primary use. All horse-related exposures must be insured.
Declare All Owned / Leased Horses, On or Off Premises.
1. Number of Owned & Leased Horses Used for:
a. Instruction to Others (ie- school horses) ______
b. Pony Rides ______
c. Rental Rides to Others ______
d. Trail & Pack Trips ______
2. Number of Horses Leased to Others: ______
3. Number of Owned Horses Used for:
a. Pleasure:___; b. Show:___; c.Training:___;
d. For Sale:____; e. Racing:_____; f. Other:_________
4. Number of Horses Used for Breeding:
a. Mares:___; b. Stallions:___; c. Foals/Weanlings:____
Total of Sections 1-4: ________
5. Number of Horses Not Owned by Applicant Used for:
a. Boarded used by applicant as School Horses _____
b.
Furnished by Independent Instructors for Lessons to Others___
c. Boarding/Pasturing _____
d. Breeding Only
(incl. mares kept on premises until foaling)___
e. Training (Breed:___________________ ) _____
f. Racing (Breed: ___________________ ) _____
g. Lay Ups
for rest vet care / rehabilitation _____
h. On Consignment for Sale (Breed:___________) _____
i. Other: _________________________________ _____
Total of Section 5: ________
Section 5 - Premises Owned and/or Leased
Answer all questions in this section. Coverage is for the applicant’s equine and livestock operation only.
1. a. Does the applicant lease any part of their land or operation to others? (Provide certificate of insurance.) Yes No
If yes, describe: _________________________________________________________________________________
b. Is there anyone other than applicant living on premises?
Yes No
If yes,
tenant employee relative other:___________________________________________________
2. a. Fencing-Type: ______________________; Age: (years)____; Condition:_________________
Submit photo of fence.
b. If “barbed wire” fence: Number of strands: __________
c. How often is fencing checked?
Daily; Weekly; Monthly; Other:______________________________
3. a. Does the applicant allow people not boarding horses at the applicant’s facility to use the facility?
Yes No
b. If yes, mark all applicable:
Haul-in’s; Practices for: team penning; roping; polo; Other:
c. Number of days yearly: ________ Average participants daily: __________ Gross Receipts $__________________
4. a. Does the applicant own, lease or use
cattle; llamas; and/or alpacas? Yes No
b. Number head of cattle: _________; llamas: ___________; alpacas: __________
c. Use of cattle: ____________________; llamas: _____________________; alpacas: _________________________
d. Does the applicant have slaughtering or processing on premises?
Yes No
5. a. Number of dogs owned by applicant: ____
None
b. Number of dogs not owned by applicant:___
None Owned by:_________________________________
c. Breed of dog(s):(If mixed, provide primary breed.) ___________________________________________________
d. Have any dogs been trained for guard duty or drug detection?
Yes No
e. Have there been any incidents of aggressive behavior including biting?
Yes No
f. Are all dogs confined
when guests or the public (including boarders & students) are on the premises? Yes No
g. Does the applicant allow dogs not owned on the premises? (Provide details.)
Yes No
6. a. Does the applicant have any bleachers or grandstands? (Submit photo.)
Yes No
b. If yes: Does the applicant:
Own or Rent;
Are they:
Permanent or Temporary; Do they have handrails? Yes No
c. What is the construction:_____________ / Age:(years)___ / Condition:_______ / Height:___ / Total seating capacity:___
d. Who erects the bleachers if they are not owned by the applicant: _______________________________
App-Commercial Equine Liability 8-11-09 Page 3 of 7
Section 6 - Additional Liability Exposure
1. a. Does applicant own/lease/use any of the following? Yes No (Indicate all vehicles used.)
Note: No liability coverage for Three-wheel All-Terrain Vehicles.
None
# of
Vehicles Personal Use
Farm Use
Rides to
Public
All Terrain Vehicles / Utility Vehicle
______
Buggies
______
Carts
______
Golf Carts
______
Dirt Bikes/Motorized Scooters/ Mopeds
______
Snowmobiles
______
Carriages
______
Sleds
______
Wagons
______
Other: _________________________
______
Use of any above vehicle is limited to use by the applicant/employee for horse operation only.
To apply for ATV coverage, visit www.markelinsuresfun.com.
b. Are any of the above used by: Boarders; Guests; Volunteers; Anyone under 16; Other:______? Yes No
c. Are drivers required to be licensed in the applicant’s state?
Yes No
2. Does the applicant perform/participate in parades?
Yes No # of parades: ____; # of horses used per parade: ____
Please provide name of parade(s): _____________________________________ ; Size of parade(s): ____________
3. Does the applicant conduct the following:
a. Trail rides, rental/saddle animal for hire? (Not including riding instruction, or trails available for boarders.) Yes No
b. Hay rides, sleigh rides, carriage rides, pack trips, hunting or fishing trips?
Yes No
4. a. Does the applicant hire any part time or full time employees?
Yes No
If yes, number of part time: ____; number of full time: ____
b. Does the applicant carry Workers Compensation/Employers Liability?
Yes No
c. Does the applicant have
leased or temporary employees? Yes No
If yes, number of leased: ___ number of temporary: ___
d. Does the applicant have any volunteers working for them? If yes, number of volunteers: ____
Yes No
Explain duties on separate page.
e. Does the applicant have any exchange labor working for them?
Yes No
If yes, explain: ______________________________________________________________________________
NOTE: “Bodily injury” to any person arising out of and in the course of that person acting on behalf of the applicant, whether through
employment, voluntarily or otherwise, expressly is not covered by the general liability policy applied for with this application.
5. Are any other businesses being conducted on the applicant’s premises? If yes, provide details on a separate page.
No Other Operation Home Day Care Petting Zoos
Bed & Breakfast Kennels RV Hookups / Campsites
Fruit & Vegetable “Pick Your Own” Retail Store (tack, feed, food, etc.) Other:__________________
Section 7 - Safety Program
1. Who is the primary manager of the applicant’s operations? Applicant Other
If other, Name-_____________
Employee or Independent Date of Birth:________________
Provide management experience:____________________________________________________________________
2. Is there a closed circuit t.v. monitor of the facility or a night watchman with hourly watch?
Yes No
3. a. Does the applicant abide by the equine liability law in the applicant’s state?
Yes No
b. Does the applicant require a signed waiver/release for all equine activities? (Submit copy.)
Yes No
c. Is the signed release kept on file for a minimum of 5 years?
Yes No
d. Does the applicant have safety and barn rules posted? (Submit copy or photo.)
Yes No
e. Does the applicant have emergency evacuation procedures?
Yes No
f. Is smoking permitted in the barn or immediate area?
Yes No
g. Does the applicant have “No Smoking” signs clearly posted?
Yes No
h. Does the applicant have working smoke alarm systems in their barns/arenas/stables?
Yes No
i. Does applicant have fully charged & mounted fire extinguishers in barns/arenas/stables?
(Submit photo.) Yes No
4. a. Are ASTM/SEI certified helmets required at all times while mounted by:
Everyone; Everyone under 18; or not required?
b. Does applicant require signed helmet rejection forms from those who don’t wear an ASTM/SEI certified helmet? Yes No
c. Check safety gear required: Boots/Heeled Shoes Long Pants Gloves Other: ___________________
d. Explain other safety procedures followed: __________________________________________________________
App-Commercial Equine Liability 8-11-09 Page 4 of 7
Section 8 - Clinics/Independent Clinicians
-
-
No Exposure or Exposure (With or without income)
1. a. Does the applicant hold clinics? Yes No If yes, # of days per year: _______________
b. Are clinics conducted by:
Applicant Independent Clinician
c. What are the annual receipts for clinics conducted by applicant: $_____________________________________
2. a. If Independent Clinician, name of Independent Clinician: ________________________________________________
b. Do they have their own insurance∗?
Yes No
c. Is the Independent Clinician certified?
Yes No
d. How many clinics are conducted by independents per year: _____; # of days: _____;
Average number of participants/day: ______
3. a. Any clinician under 18 years of age?
Yes No
b. Do all clinicians have a minimum of 5 years experience conducting clinics?
Yes No
4. Indicate dates of clinics: __________________________________________________________________________
∗
Provide proof of coverage, naming applicant as additional insured owner of premises, with an “A” rated admitted carrier with the
same liability limits as applicant.
Section 9 - Boarding/Breeding/Training/Racing of Horses
No Exposure or Exposure (With or without income)
On premises liability coverage is provided for the independent trainer if added to the applicant’s policy. If any trainer requires OFF
premises coverage, they must complete their own application. We can provide a quotation to cover their training operation.
Boarding: 1. Does the applicant provide riding facilities for their boarders?
Yes No
None 2. If yes, is the facility an: Indoor Arena Outdoor Arena Trails Other: ___________________
3. Is there supervision when boarders are using the facility?
Yes No
Breeding: 1. Are outside mares kept on premises until foaling? Yes No Number of outside mares: _______
None 2. Any breeding horses used for pleasure/show/training/racing? Yes No
3. Method of breeding conducted by applicant on premises:
Live Breeding; Artificial Insemination
4. Are owned stallions shipped off premises for breeding?
Yes No
5. Any sales and/or shipment of semen? (No products liability.)
Yes No
Training is: “Instruction given to horses. Includes demonstration/instruction to owners of horses in training.”
None 1. Training is given by: (Check all that apply.) Applicant; Employee; Independent Trainer
2. a. Does the applicant have a trainer on staff ?
Yes No
b. How many independent horse trainers utilize the applicant’s facility: ________
3. Type of Training:
Race Show–Type of show:_____________ Other type of training: __________
4. If horses are not kept on premises, where are they kept?
Training/Boarding Facility; Racetrack;
Other: __________________________________________
5. Does the applicant attend off-premise shows with horses in training?
Yes No
6. Do ALL independent horse trainers carry their own general liability insurance∗?
Yes No
∗
Provide proof of coverage, naming applicant as additional insured owner of premises,
with an “A” rated admitted carrier with equal or greater liability limits as applicant.
Complete this section for ALL
trainers including independent trainers, applicant, and employees working on behalf of the
applicant or at applicant’s facility. (MUST BE AT LEAST 18 YEARS OF AGE)
Trainer # 1
a. Trainer’s Name: ____________________________________ DOB: ______________
b. Type of Training Offered:____________________
c. Trainer is:
Applicant; Employee; Independent Number of years experience as a trainer: ________
d. Any licenses/certification for training:
Yes No
e. Give details and competition experience: _____________________________________________________________
Trainer # 2
a. Trainer’s Name: ____________________________________ DOB: ______________
b. Type of Training Offered:____________________
c. Trainer is:
Applicant; Employee; Independent Number of years experience as a trainer: ________
d. Any licenses/certification for training:
Yes No
e. Give details and competition experience: _____________________________________________________________
App-Commercial Equine Liability 8-11-09 Page 5 of 7
Section 10 - Riding Instruction to Students No Exposure or Exposure (With or without income)
Instruction is: “Teaching students to ride on their horses or horses provided by applicant or independent instructor.”
1. Riding instruction is given by (check all that apply):
Applicant; Your Employee; Independent Instructor
(Instructors must be a minimum of 18 years old.)
2. How many school horses do you use at any one time for lessons: _________
3. Number of lessons per week on school horses owned, used, leased by applicant: ____; Charge per lesson: $_____;
Number of weeks per year: _____
4. a. Number of lessons per week on student owned horses: ____ Charge per lesson: $_____;
Number of weeks per year: _____
b. Receipts for riding Instruction given to students on their own horses by named insured or employee:$____ annually
5. Does anyone under the age of 18 give riding instruction or clinics on your premises?
Yes No
6. a. Do you provide riding instruction for handicapped students?
Yes No
b. Are you a North American Riding for the Handicapped Association center member?
Yes No
7. Level of instruction given:
Beginner: Ratio of students:____ to instructor: _____ Number of students- Under age 18: ____ Over age 18: ____
Intermediate: Ratio of students:____ to instructor: ______ Number of students- Under age 18: ____ Over age 18: ____
Advanced: Ratio of students:____ to instructor: ______ Number of students- Under age 18: ____ Over age 18: ____
8. How many schooling shows per year: ________ # of spectators: _________
9. Stallions used during instruction for:
Beginner; Intermediate; Advanced; No stallions used for instruction.
10. Do you use lesson plans which are adapted for each class or student?
Yes No
11. Do all instructors wear a helmet while riding?
Yes No
12. Is instruction given on your premises by independent instructors?
Yes No
If yes: a. How many independent instructors: ______ b. How many students: ______
c. Receipts for independent Instructors giving instruction to students on student owned horse: $______ annually
d. Do you obtain certificates of insurance from independent instructors? (If yes, provide copy.)
Yes No
Please complete below for all riding instructors (self, employees, independents) utilizing your facility. If an instructor(s) requires
coverage for other than working at your facility, they must complete their own application. We can provide a quotation to cover
their riding instruction operation.
Instructor # 1
1. Instructor’s Name: ____________________________________ DOB: ________
2. Type of Instruction:_______________________
3. Instructor is:
Self Your Employee Independent Instructor
4. Number of years experience as a riding instructor: ________
a. Certified by:
ARIA; CHA; NARHA; USHJA; Other:________ Not a certified instructor
b. Give details on competition experience: __________________________________________________
5. If instructor is an independent, does instructor need to be added to this insurance policy?
Yes No*
6. Does instructor provide horses used for lessons?
Yes No
If yes, number of horses provided:_____
Instructor # 2
1. Instructor’s Name: ____________________________________ DOB: ________
2. Type of Instruction:_______________________
3. Instructor is:
Self Your Employee Independent Instructor
4. Number of years experience as a riding instructor: ________
a. Certified by:
ARIA; CHA; NARHA; USHJA; Other:________ Not a certified instructor
b. Give details on competition experience: __________________________________________________
5. If instructor is an independent, does instructor need to be added to this insurance policy?
Yes No*
6. Does instructor provide horses used for lessons?
Yes No If yes, number of horses provided:_____
Complete information for over two instructors on additional paper.
* If no, provide proof of coverage naming applicant as additional insured owner of premises with an “A” rated admitted carrier
with the equal or greater liability limits as applicant. Independent instructors operating under your name can be added as
additional insured with appropriate charge, but coverage is limited to your operations only.
App-Commercial Equine Liability 8-11-09 Page 6 of 7
Section 11 - Care, Custody & Control - Legal Liability
Not Eligible for this Coverage: Veterinarians, Equine Dentists, Commercial Transporters, Rehabilitation
Centers & Embryo Transplant Facilities.
Legal liability provides coverage arising from the applicant’s negligence resulting in injury to or death of horses the
applicant does not own in their care, custody, and control. Coverage includes cost to defend any suit alleging injury or
death. This cannot be restricted by contractual or hold harmless agreements. The coverage for the exposure is excluded in
most general liability policies. Settlements are based on actual cash value at time of loss. Please read wording in policy
coverage form.
Please check one: I,
ACCEPT or DECLINE Care, Custody & Control Coverage. PLEASE QUOTE.
Check a box below to indicate choice of Care, Custody & Control coverage.
If the applicant requires different limits, please call us.
Limit Per Horse / Limit Per Horse / Limit Per Horse /
Maximum Loss Per Policy Year
Maximum Loss Per Policy Year Maximum Loss Per Policy Year
$ 5,000 / $ 25,000 $ 10,000 / $ 100,000 $ 50,000 / $ 250,000
$ 5,000 / $ 50,000 $ 25,000 / $ 100,000 $ 100,000 / $ 500,000∗
$ 10,000 / $ 50,000 $ 25,000 / $ 250,000 Other: __________ / _____________
∗Substantiation of Value Form may be required when values are $100,000 and over.
1. a. Are horses not owned kept:
in stalls or in pasture? b. Number of pastured acres: _____
c. Are pastures fenced?
Yes No d. Are shelters provided in each pasture? Yes No
2. a. Average value of horses not owned in the applicant’s care: $_______________________
b. Number of horses the applicant does not own: _______________
3. Does the applicant store hay in the same barns as the horses not owned?
Yes No
4. Does the applicant require mortality coverage for horses in the applicant’s care, custody and control?
Yes No
5. a. Does the applicant own, lease/rent or use a vehicle in order to transport horses not owned?
Yes No
b. Number of vehicles: ________ Number of trips per year: ________ Radius of operation: _________
c. Have any drivers had any traffic violations within the past 5 years?
Yes No
If yes, explain: _______________________________________________________________________________
d. Type and capacity of box or trailer: _______________________________________________________________
e. Does the applicant have a safety maintenance program for vehicle(s)? (Submit a copy.)
Yes No
Current copy of drivers list must be submitted. (MVRs may be required.)
6. Does the applicant own, lease or use any facility for rehabilitation or surgical purposes?
Yes No
If yes, describe: _________________________________________________________________________________
7. Distance from fire department: ________________ Number of miles to regular vet? _______________
8. Does the applicant use an:
equine swimming pool; hot walker; and/or tread mill? Yes No
9. Are extension cords used in the barn?
Yes No
Barn Information:
Additional barns complete on separate page.
Barn #1 Location #: ________ Barn #2 Location #: ________
Construction Type:
____________________ ____________________
Year Built∗:
____________________ ____________________
Year of Updates:
Mark N/A if no heating,
plumbing and/or electricity
in building.
Heating: ________ N/A
Roof: ________
Plumbing: ________
N/A
Wiring: ________
N/A
Heating: ________
N/A
Roof: ________
Plumbing: ________
N/A
Wiring: ________
N/A
Does barn have an
apartment?
If yes, occupied by:
Yes No Tenant Employee
Other: ___________
If yes, occupied by:
Yes No Tenant Employee
Other: ___________
Heat Type:
None Wood Stove
Forced Warm Air Portable Heaters
Other: ______________
None Wood Stove
Forced Warm Air Portable Heaters
Other: ______________
Protective Devices:
None Lightning Rods
Sprinkler System Fire Extinguisher
Other: _________________________
None Lightning Rods
Sprinkler System Fire Extinguisher
Other: _________________________
Average number of horses
applicant does not own
in each barn:
____________________ ____________________
∗
Barns older than 30 years with no electric updates within 20 years require a certified electrician’s statement that wiring is
safe for current usage.
App-Commercial Equine Liability 8-11-09 Page 7 of 7
Section 12 - Services and Sales - No Exposure This policy does not cover products liability.
1. a. Does the applicant perform farrier services?
Yes No
Annual gross receipts: $___________
On Premises Off Premises
Owned Horses Horses Not Owned
b. Does the applicant have: Apprentice
Yes No If yes, payroll $___________
Helper
Yes No If yes, payroll: $____________
2. Does the applicant sell hay or feed?
Yes No If yes, gross receipts $____________
3. Does the applicant prepare or mix feed for animals for sale or consumption?
Yes No
4. a. If the applicant manufactures and/or repairs any goods sold, please explain:__________________________
N/A
b. Does the applicant repair riding equipment for others?
Yes No
5. a. Does the applicant sell
tack, clothing, other: __________________________? Yes No
b. If yes, annual gross receipts $______ Location on premises: _________________________ Sq. Footage: ______
6. a. Does the applicant have food or snack bar sales? (Liquor liability not covered.)
Yes No
b. If yes, annual gross receipts $______ Location on premises: __________________________ Sq. Footage: _______
c. Does the applicant have:
Ansul Systems; Commercial Grill System; Deep Fat Fryers
d. Does the applicant have vending machines?
Yes No
If yes, are they anchored securely?
Yes No (Submit photo.)
e. Does the applicant have working
fire extinguishers and/or smoke alarm systems? Yes No
Section 13 - Horse Events/Competitions - No Exposure or Exposure (With or without income)
1. Type of events held: Shows Rodeos∗ Polo matches Other:
∗If yes, please complete Rodeo Supplement.
2. Events are conducted and/or managed by:
Applicant Other: _______________________________________
3. Total number of event days per year: conducted and/or managed by applicant: ___________
not conducted and/or managed by applicant: ___________
4. What is the maximum number of participants on grounds per event day? ____________
5. Maximum number of spectators on grounds per event day: ___________
6. Indicate dates of events: _________________________________________________________________________
7. Does applicant have vendors at the events?
Yes No
(Provide proof of coverage, naming applicant as additional insured owner of premises, with an “A” rated admitted carrier
with equal or greater liability limits as applicant.)
8. Describe security and safety procedures at events: ______________________________________________________
9. Recognized by what National and/or International Sanctioning Organizations: N/A ___________________________
Section 14 - Horse Sales - No Exposure Note, this policy does not cover horses as a product.
1. Does the applicant sell from their own premises?
Yes No
Explain any other method of sales: _________________________________________________________________
2. How many horses does the applicant sell annually: Owned by applicant: ________ Owned by others: ________
3. Is the buyer allowed to test ride?
Yes No
If yes, type of test ride given:
Open Field Arena Other:_________________
4. Is supervision provided during the test ride?
Yes No
5. Are waivers signed for all test rides?
Yes No (Must be kept on file for 5 years.)
6. Does the applicant sell horses as an agent for others?
Yes No Receipts for selling as agent: $____________
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or another
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 subjects the person to criminal and [NY: substantial] civil penalties. In DC,
LA, ME, TN and VA, insurance benefits may also be denied.
A
A
u
u
t
t
h
h
o
o
r
r
i
i
z
z
a
a
t
t
i
i
o
o
n
n
I hereby certify that to the best of my knowledge and belief the information provided is true and correct and
that no information which would materially affect this insurance has been withheld.
Signature Date Broker Signature
(if applicable)
Date
How did you hear about Markel:
Magazine Ad Referral Convention Web Site Other
Describe: _____________________________________________________________________________________
Thank you for choosing Markel, The Insurance Company With Horse Sense
®
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Commercial Equine Liability & Care, Custody & Control (Abram Interstate Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document