Fillable EQUESTRIAN SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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EQUESTRIAN SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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  • 192 other fields

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Page 1 of 7
EQUESTRIAN SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal? Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal? Yes No
Claims made? Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) Applicant’s product brochure, catalog, or marketing materials if a website is not available
c) Detailed diagram of courses, trails, etc., including obstacle and jump height and distance measurements
d) Kinsale Equine Animal Supplemental Table
3) What are your operations? Check all that apply:
Equestrian Lessons – Riding or Dressage
Equestrian Lessons – Racing Jockey or Rodeo
Equine Training – Dressage, Performance, Stunt, or Obstacle Course
Equine Training – Racing
Equine Amusement Rides or Attractions/Petting Zoos
Equine Driven/Pulled Vehicles
Camps or Retreats – Varied Activity/Not Equestrian Specific
Camps or Retreats – Equestrian
Non-medical Equine Assisted Therapy
Equine Boarding Services
Leasing of Equine Animals
Equine Events – Hunting
Equine Events – Breeding, Show, and Competition (non-racing, non-rodeo)
Equine Events – Racing
Equine Events – Rodeo or Polo
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 7
4) What are your projected receipts for the coming year? $
5) Do you operate seasonally only? Yes No
a. If yes, what is your operating season?
b. How many seasons/years have you been in operation?
6) Are you subject to any state or local licensing or regulation? Yes No
a. If yes, list regulations/licenses:
7) How many years have you been in operation?
a. How many years of experience do you have working with equine animals?
b. On average, how many years of experience do your employees have working with equine animals?
8) Do you run criminal background checks on all employees? Yes No
a. Are past convictions for crimes involving minor children, animal abuse, or sexual Yes No
misconduct exclusionary criteria for hiring?
b. What is the minimum age for employment?
9) Does your operation have any age restrictions for participants? Yes No
a. If yes, what age? __
10) Please indicate the safety measures required of all riders:
a. Helmets? Yes No
b. Gloves? Yes No
c. Closed-toe shoes with a heel? Yes No
d. Other : Yes No
11) Do you have a veterinarian or other equine medical care specialist on premise? Yes No
a. How frequently are animals assessed for physical health, including temperament affecting changes (loss of vision,
loss of hearing, arthritis, etc.)?
b. How old is your oldest equine animal?
c. How old is your youngest equine animal?
d. Do you allow riding of intact males/stallions? Yes No
12) Please check all operations in which you are engaging:
Riding/Dressage Lessons – Children under 13 Riding/Dressage Lessons – Children 13 to 18
Riding/Dressage Lessons – Adults Racing Jockey/Rodeo Lessons – Children under 13
Racing Jockey/Rodeo Lessons – Children 13 to 18 Racing Jockey/Rodeo Lessons – Adults
Day Camp (varied) – Children under 13 Day Camp (varied) – Children 13 to 18
Day Camp (equestrian) – Children under 13 Day Camp (equestrian) – Children 13 to 18
Day Camp (varied) – Disabled Minors Day Camp (varied) – Disabled Adults
Day Camp (equestrian) – Disabled Minors Day Camp (equestrian) – Disabled Adults
Overnight Camp (varied) – Children under 13 Overnight Camp (varied) – Children 13 to 18
Overnight Camp (equestrian) – Children under 13 Overnight Camp (equestrian) – Children 13 to 18
Overnight Camp (varied) – Disabled Minors Overnight Camp (varied) – Disabled Adults
Overnight Camp (equestrian) – Disabled Minors Overnight Camp (equestrian) – Disabled Adults
Equine Assisted Non-medical Therapy – Minors Equine Assisted Non-medical Therapy – Adults
Page 3 of 7
13) How many campers, students, or therapeutic participants are on premise at one time?
a. What is the staff to participant ratio?
b. What is the typical age range of your participants?
c. If you accept participants in a large variety of ages, are groups separated by age range? Yes No
d. Are groups separated by gender? Yes No
14) Describe the main equestrian activities participants engage in (attach another sheet if necessary):
15) Do you prepare or provide any meals to participants? Yes No
16) If you operate a camp (day or overnight), please complete the following:
a. Do you have any water hazards at your location (pools, ponds, lakes, etc.)? Yes No
b. If yes, is the area access restricted when not in use and attended by a lifeguard when in use? Yes No
c. Do you have any trampolines, zip lines, or inflatable amusements of any kind? Yes No
d. Is the camp religiously affiliated or requiring participants to engage in religious activities? Yes No
d. Do you have any after dark/twilight activities? Yes No
e. If yes, do any after dark activities involve equestrian animals? Yes No
17) If you operate a camp for disabled or medically sensitive participants, please complete the following:
a. Does your camp provide services for a specific disability or medical condition? Yes No
b. If yes, which condition(s)?
c. Are appropriate medical or therapeutic staff on premises at all times while participants Yes No
are present?
d. How far are you from the nearest hospital? miles
18) Do you distribute medication to participants? Yes No
a. If yes, is distribution limited to prescription only? Yes No
b. If no to a., are participants required to provide their own over the counter medications? Yes No
c. How are medications secured?
19) If you operate an overnight camp, please complete the following:
a. What sleeping accommodations are provided (tent, cabin, dormitory, etc.)?
b. Do all sleeping accommodations have working smoke detectors? Yes No
c. How many days and nights do camp sessions run?
d. Describe your lights out/evening security precautions:
20) Do any riding or other equestrian activities occur outside of fenced/enclosed locations? Yes No
a. If yes, please describe:
21) Are equine animals stabled on premises? Yes No
a. If yes, how is access to the animals restricted?
b. Are all animals used during activities owned by you or the participant? Yes No
c. If no, please clarify:
Page 4 of 7
22) If you are providing rodeo lessons, does training involve any animals other than horses Yes No
(bulls, steer, hogs, etc.)?
a. If yes, what animals?
b. Do you utilize any mechanical trainers (electric or manual)? Yes No
23) What is the longest period an animal is left under your control?
24) What is the highest value animal left under your control?
25) What is the average value of animals left under your control?
26) What is the maximum number of animals under your control at a time?
a. Number of stalls:
27) Do you obtain releases relieving you from claims of bodily injury or property damage, including Yes No
injury to animals?
28) Who is responsible for the regular feeding of the horses under your control?
29) Do you engage in any breeding or foaling operations? If yes, please attach additional information. Yes No
30) If you are training for show jumping, cross-country, or steeplechase, please complete the following:
a. What is the maximum height of jump you train?
b. What is the maximum jump or obstacle distance you train?
31) Do you provide any transport or shipment of animals:
a. By vehicle? Yes No
b. By rail? Yes No
c. By ship? Yes No
d. By air? Yes No
32) Please check all operations in which you are engaging:
Pony Rides (wheel/carousel) Pony Rides (bridle led)
Pony or Horse Rides (enclosure only) Pony or Horse Rides (open trail)
Horse Carriage – Private Hire Horse Carriage – Public Hire
Petting Zoo Equine Rental – Lessons or Riding
Equine Rental – Film, Stage, or TV Performance Equine Rental – Farm Labor/Driving
33) For equine amusement and attractions, please complete the following:
a. Are parents of minor children required to be present at all times during participation? Yes No
b. Have you ever had a biting or kicking incident? If yes, please attach details. Yes No
34) How long is an animal in your possession and training prior to use by or with others?
35) If you are operating a horse drawn carriage, do you operate in urban areas? Yes No
36) If you are engaging in open trail rides, please complete the following:
a. Are trails ridden by staff before the first participant ride of the day to inspect for hazards? Yes No
b. Do any trails approach roadways or hunting zones? Yes No
c. Are all trails on your privately held land? Yes No
d. Do you allow participants to bring their own horses or ponies? Yes No
Page 5 of 7
e. If you are guiding minors, how many minor children per staff member is permitted? Yes No
f. Are minor children required to be accompanied by a parent or guardian? Yes No
g. Are all participants required to sign a waiver? Yes No
h. Has this waiver been reviewed by legal counsel? Yes No
37) If you are providing equine animals for film, stage, or TV use, are your operations approved Yes No
by the American Humane Association?
38) Do you host any gymkhana, horse mounted marksmanship, or equine stunt events? Yes No
39) Do your events involve any animals other than equine animals? Yes No
a. If yes, please describe:
40) Is alcohol served at your events? If yes, complete a.-j. below. Yes No
a. Do you have a Liquor License? Yes No
b. If yes, please provide license number:
c. Has your liquor license ever been revoked or suspended? Yes No
d. Do you carry separate Liquor Liability insurance? Yes No
e. If Yes, please provide carrier and policy number:
f. Have you experienced any liquor violations or claims in the last five years? Yes No
If yes, please attach details.
g. Do you have written guidelines for ID checking? Yes No
h. Are alcohol servers trained in documented, responsible alcohol serving techniques Yes No
(TIPS, TAM, RAMP, BEST, or similar)?
i. Do you train employees on the handling of minors or intoxicated customers? Yes No
j. If yes, please provide details:
41) Is gambling permitted on premise? Yes No
a. If yes, please provide your gaming control permit or license number:
42) Do you provide any judging, officiating or scoring of events? Yes No
43) Do you have emergency medical personnel and crowd control security on site during all events? Yes No
44) Do you have emergency veterinary personnel on site during all events? Yes No
45) Are all event participants required to sign a waiver absolving you of all liability for bodily injury Yes No
and property damage, including any injury to animals?
a. Has this waiver been reviewed by legal counsel? Yes No
46) Who is responsible for the design of your event area (track, course, etc.)?
a. How frequently is the area inspected?
b. Are event participants given the opportunity to inspect the area before the event begins? Yes No
47) Do you have any junior/youth events or event divisions? Yes No
a. If yes, how young are the youngest participants allowed?
48) How far are the nearest spectator areas from event areas?
a. Is access to all animals restricted to event participants and staff only? Yes No
Page 6 of 7
49) If you are hosting hunts, please complete the following:
a. Is the hunt of wild animals, released game, or a dummy/prop?
b. Are dogs used on the hunt? Yes No
c. Are hunters permitted to discharge a weapon from horseback? Yes No
d. If yes to c., please describe safety precautions taken:
50) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company. If Yes, please attach and explanation.
51) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages or accidents arising out of or related to your operations that a reasonably
prudent person might expect to give rise to a claim or lawsuit whether valid or not
which might directly or indirectly involve the company? If yes, please attach an explanation.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
Page 7 of 7
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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EQUESTRIAN SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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