Fillable EQUINE FARM APPLICATION (Abram Interstate Insurance)

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EQUINE FARM APPLICATION (Abram Interstate Insurance)

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6/1/2016 1
LLC
Insured
Mortgagee
FEIN#:
Loss History:
1. No
2. No
3.
No
4.
No
5.
SCHEDULED PERSONAL PROPERTY
Individual
Corporation
Billing:
Entity Type:
Direct Bill
Agency Bill
Partnership
Pay Plan:
Bill To:
Requested Effective Date:
AUTO
EMPLOYEE BENEFITS LIABILITY
WATERCRAFT
MONOLINE LIABILITY
MONOLINE PROPERTY
EQUINE CARE, CUSTODY, CONTROL
NONE
(List all losses for the past 5 years that affect coverage lines requested above)
Yes
fraud, bribery, arson or any other arson-related crime in connection with this or any other property?
How many years experience/in the business with horses?
Yes
Customer#/SubID
Producer#
Prior Carrier Information:
Coverage Line
Company
Property
Care, Custody, Control
Umbrella
Liability
Mailing Address:
Are you age 18 or over?
Yes
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent
# of years
Expiring Premium
EQUINE FARM APPLICATION
Company Use Only
Agency
Phone#
Name/
Address:
Application Date:
Quote needed by:
APPLICANT INFORMATION
hiring?
Open/Closed
Paid
Coverage Line
During the last five years, has any applicant been indicted for or convicted of any degree of the crime of
Have you been declined, cancelled or non-renewed in the past 3 years?
County:
Phone#:
GENERAL UNDERWRITING QUESTIONS
A State specific ACORD Auto Application in order to quote Auto. ACORD Watercraft Application required for
Watercraft. Employee Benefits Liability Supplemental Questionainaire required for EBL Coverage
Description
Named Insured:
Additional Named Insured Supplemental Attached (Required for multiple Named Insureds)
Phone#
Coverages to
be quoted:
PACKAGE
UMBRELLA
Inspection Contact Name:
If yes, explain:
Web Address:
Email:
Yes
6/1/2016 2
1.
2.
3
4.
/ / / /
% % % %
/ / / /
No No No No
CS CS CS CS
CS CS CS CS
No No No No
If no Property Coverage is desired, please skip to the General Liability Section at the bottom of Page 4
LOCATION SCHEDULE
PC = Protection Class
Additional Locations Supplemental Attached
DWELLING SCHEDULE
Additional Dwellings Supplemental Attached
Local
Ordinance or Law Coverage
RC
Dwelling#1
Sprinkler System & Maint Contract?
RC
(2) BA = Basic, BR = Broad, SP = Special, SP/BR = Special all other/Broad Contents
ABBREVIATION KEY:
(1) RC = Replacement Cost
(3) Extended Replacement Cost (E2 Value required) - Up to 125% Limit of Insurance for Coverage A includes
PROPERTY UNDERWRITING QUESTIONS
Acres
Owned
PC
Roof
Dwelling#4
Dwelling#3
Roof
Yes
Local
Local
Yes
Local
Local
Yes
Deductible Amount
Yes
Building Name
Cause of Loss (2)
RC
Dwelling Enhancement Endorsement
Earthquake Coverage
Location # (see Location Schedule)
Dwelling #2
Wind/Hail Deductible %
B. Appurtenant Structures (10%)
C. Household Contents (70%)
(1)
A. Dwelling Limit
D. Loss of Use (20%)
Year Built
Occupancy: Owner/Tenant/Employee
Construction Type
(4)
Roof Construction
(5)
Total Area/ Area of Living Area (sq ft)
Roof
Roof
Building Class
Distance to Hydrant/Fire Station
RC
Full-time, Part-time or Primary?
Plumbing
Electrical
Plumbing
Electrical
Plumbing
Electrical
Year of Updates (for Dwellings
over 30 years of age)
Heating
Plumbing
Electrical
(4) Construction Type Choose: Frame, Masonry, Steel frame, Pole or Mobile Home/Mobile Building
(5) Type of Roof Choose: Asphalt, Fiberglass, Metal, Tile, Cedar
Yes
Heating
Heating
Heating
Yes
(6) CS = Central Station alarm monitored by remote monitoring company
Yes
Local
Smoke Detectors Present?
Yes
Burglar Alarm?
(6)
Local
Fire Alarm?
(6)
Local
Zip
County
City/State
Street Address
Dwelling is Located Inside City Limits
Extended Replacement Cost
(3)
6/1/2016 3
/ / / /
% % % %
No No No No
CS CS CS CS
CS CS CS CS
No No No No
No No No No
1. No
2. No
3. No
4. No
Abbreviation Key:
Buildings
Loc #
Loan#
OUTBUILDINGS SCHEDULE
Additional Outbuildings Supplemental Attached
MORTGAGEES
Additional Mortgagees Supplemental Attached
If Yes, send completed Wood-burning Stove Questionnaire for each building with a Wood Stove
Mortgagee Name/Address
Year Built
# of Open Sides on Building
Area of any Office/Living Area (sq ft)
Use of Outbuilding?
Location # (see Location Schedule)
# of Stories
Are there any vacant or unoccupied structures on your property?
Yes
Outbuilding Limit
Do any buildings on any of your property have a Wood Burning Stove?
Yes
Wind/Hail Deductible %
Distance to Hydrant/Fire Station
Deductible Amount
Building #1
Building#2
Cause of Loss (Basic/Broad/Special)
(Optional) Inflation Guard: 4% or 6%
Building Name
Building#3
Building #4
# of Apartments in Outbuilding?
Building Class
Earthquake Coverage?
Total Area
Construction Type
(1)
Heat Type
Roof Construction
(2)
Full or part-time occupancy in Apt?
Type of Occupancy in Apartment?
Yes
Local
Local
Yes
If Yes, Limit?
Burglar Alarm?
Year of Updates (for Buildings
over 30 years of age)
Roof
Heating
Roof
Heating
Roof
Heating
Roof
Yes
Local
Avg # hay bales stored in building
Heating
Fire Extinguishers?
Is Extra Expense Coverage Needed?
Yes
If Yes, Limit?
Local
Yes
Smoke Detectors in Living Quarters?
Yes
Yes
Local
Yes
Is Loss of Farm Income Coverage needed?
(1) Construction Type Choose: Frame, Masonry, Steel frame, Pole or Mobile Home/Mobile Building
If yes please describe structure and explain oversight/security and plans for occupancy or sale:
(2) Type of Roof Choose: Asphalt, Fiberglass, Metal, Tile, Cedar
Sprinkler System & Maint Contract?
Yes
Yes
Yes
Yes
Yes
Local
Yes
Local
Fire Alarm?
Local
%
%
%
%
6/1/2016 4
SCHEDULED PERSONAL PROPERTY
FARM PERSONAL PROPERTY
1
2
3
4
5
6
7
8
1.
No
2.
Dude Ranch Polo/Horse Ball
Therapeutic or Riding for the
Handicapped
Gymkana/Mounted Games
Rodeos
Equine Coverage Extension Endorsement
Equine Sports Therapy (including massage)
Deductible:
$500
Address
Name
LOSS PAYEE SCHEDULE
$1,000,000/$2,000,000
Parades
Is the applicant involved in any of the following activities?
Entertainment/Amusements involving
Additional Scheduled Personal Property Supplemental Attached
Additional Schedule Farm Personal Property Supplemental Attached
Additional Loss Payee Supplemental Attached
Item#
custom farming?
Yes
Motorcycles, ATV's (other than resident)
Hay/Carriage/Sleigh Rides
Please explain any checked activities:
Hunting/Fishing on premises (non-residents)
If yes, please provide details:
Holds Races on Premises
(For Item # Use the number corresponding to that particular Farm Personal Property item above)
Year/Make/Model OR Description
Location
Loc#
Category: Jewelry/Fine Arts/Etc
Item Description
$1000
$2500
$5000
Other:
An appraisal or sales receipt with photos must accompany all items with an individual value of $10,000 or more
Cause of Loss:
Basic
Broad
Special
Serial #
Limit
Replacement Cost on Scheduled Tack
Replacement Cost on Scheduled Office Contents
Vaulting
Limit
(Please check activities applicable)
Pony Rides
Are you engaged in any other farm business, profession, or trade including but not limited to hay sales and
List all Equine Operations:
Fox Hunting
GENERAL LIABILITY UNDERWRITING QUESTIONS:
$100,000/200,000
$300,000/600,000
$500,000/1,000,000
Public Horse Rentals/Trail Rides
animal farms/Agritourism/Agritainment
Mounted Shooting
Equine Assisted Therapy
Company Use Only:
Limits:
6/1/2016 5
3. No
No Leashes Required? No
4.
Use of vehicles:
5. No
6. No
No
7. No
8. No
9.
No
10. No
11. No
12. No
ADDITIONAL INSUREDS
No
1.
1.
2.
3.
No
4.
5.
6.
7.
Is there a pool, aqua treadmill, hyperbaric chamber or similar item on your property?
Yes
Please provide details:
If liability coverage desired for any owned snowmobiles/ATVs/Golf Carts, please provide the following:
Is Unlicensed Farm Vehicle Liability Coverage needed?
Yes
How many vehicles?
Yes
How many?
Name/Address
Yes
How many Independent Instructors are giving instruction?
Describe the experience/qualifications of you and your employees:
Relationship to Insured
Any past claims? If yes, explain:
Recreational/Hunting
Yes
Do any non-Boarders, Associations, Pony Clubs, 4-H, Girl/Boy Scouts, etc. use your facility?
Yes
Supplemental Additional Insureds Schedule Attached
Do you lease any part of the building/land to someone else?
Type of Fencing?
Off Premises
Please list all individuals for whom Personal Liability is desired. Make sure to list any children over the
PERSONAL LIABILITY
Not Applicable
Yes
Are you/employee a certified instructor?
ATVs:
# of wheels:
Farm
Are dogs owned?
Yes
Breed:
Number of students per week given lessons by an independent instructor :
Number of students per week given lessons by you or your employee :
Receipts:
If yes, please explain:
Do you lease horses to or from others?
Yes
RIDING INSTRUCTION (Teaching the Rider)
Are all fences/gates in good condition?
If yes, please explain:
Do you judge shows?
Riding Instruction provided by:
You
Independent Instructor
Employee
By whom?
Yes
Is there an airstrip on the premises?
Yes
What is the maximum number of students per instructor per lesson?
Are clients' dogs allowed at the facility?
Yes
Yes
Age of Drivers:
PLEASE FILL OUT AND ATTACH THE ADDITIONAL LOCATION SUPPLEMENTAL
Do you have any operations or horses in any country outside of the U.S.?
Yes
What is the minimum age of the students?
age of 18. (married couples may be listed together):
IF YOU ARE REQUESTING A QUOTE FOR MONOLINE LIABILITY AND WOULD LIKE TO SCHEDULE ANY LOCATIONS
6/1/2016 6
1. No
1.
2.
3.
1.
2. No
3.
4.
1.
2. No
1.
2.
1. Are you in the business of selling horses? No
What are the annual Net Receipts for Horse Sales?
2.
3. No
4. No
1. No
No
2.
3.
4. Average Attendance:
5.
6. No
What is the total number of equines you own or lease for your own use?
Who teaches the clinics?
BOARDING OF NONOWNED HORSES
Yes
How many horses do you sell per year?
Owned by you:
What is the total # of non-owned horses including non-owned broodmares?
Retired
Sales Prep
Of those, how many are used for the following activities:
Not Applicable
Not Applicable
Owned by Others:
Is board self board or full care?
Self
Full
Total payroll related to Training:
Not Applicable
Showing
Instruction
Do you sell tack or clothing?
Number of Clinics:
Number of days per clinic:
Not Applicable
Do you hold/sponsor clinics for non-students on your premises?
Yes
Off Premises:
New
If yes, please complete the separate Day Camp Supplemental
What type of training is given?
Receipts:
Do you offer repair of tack or riding equipment?
Yes
Not Applicable
DAY CAMPS
Do you hold day camps?
Yes
Only include Owned horses not otherwise accounted for in Breeding/Training sections
SALES BY YOU
Not Applicable
Not Applicable
HORSE TRAINING (Training of horses)
None
Type of Clinics:
Pleasure Riding
Annual Payroll:
# of Owned Broodmares:
Is temporary overnight boarding provided?
Yes
Describe
Breeding Payroll:
Do you require outside clinicians to provide proof of insurance?
Yes
Do you/employee perform any type of farrier services?
Yes
Do you offer foaling services?
Yes
BREEDING
What is the method of sale? (private treaty, auction, consignments)
CLINICS
Yes
Details:
Used
Reconditioned Tack
What is the average number of horses trained per year?
# of Owned Stallions:
# of Nonowned Stallions:
OWNED HORSES
6/1/2016 7
1. No
Off Premises? No
2.
3.
4.
5. No
6. No
7. No
8. No
9. No
YES NO N/A
1. What is the maximum number of non-owned horses you have at any one location at any time?
2. Are you for hire to transport non-owned horses not normally in your care? Yes No
**Commercial Hauling of non-owned horses other than those you train/breed/board is excluded**
Maximum trips per year Radius # of horses per trip
3.
Certificate of Insurance shows WC coverage for Independent Trainers (Racehorse Training only)
Certificate of Insurance obtained from all Vendors (Horse Shows/Clinics)
Release/Hold Harmless agreement in use (Riding Instruction/Training/Boarding/Breeding/Shows)
Boarding Contract in Place (Boarding)
Lease Agreement in Place (Owned Horses Leased to Others)
State Equine Liability Signs Posted (All Exposures)
24 Hour Supervision of facility (All Exposures)
Review http://www.horse-insurance.com/law.html for state requirements
RISK MANAGEMENT CONTROLS
(Required for General Liability and Care, Custody, Control)
$50,000 per horse/$250,000 aggregate
Limits:
$25,000 per horse/$250,000 aggregate
$200,000 per horse/$500,000 aggregate
COVERAGE IS NOT DESIRED
Certificate of Insurance on file for Independent Contractors (Riding Instruction/Training)
Receipts:
Yes
Do you provide RV or camper hookups during these shows?
Yes
Do you manage/sponsor any horse shows on your premises?
Yes
Yes
Construction:
Not Applicable
Yes
Number of spectators per day:
Do you have bleachers or grandstands?
Yes
Seating Capacity:
Dates of shows:
Types of shows:
HORSE SHOWS
If yes, explain:
Do you have vendors on the premises during these shows?
Describe any losses or potential claims involving non-owned horses in the past 3 years including deaths of
any animals in your custody, even if a claim was not presented:
If yes, explain items sold:
Height:
$100,000 per horse/$300,000 aggregate
Number of hookups:
Receipts:
Do you directly provide concessions during these shows?
Owned
Rented
EQUINE CARE, CUSTODY, CONTROL SECTION
Do you sell feed, grain, hay or shavings to participants?
Yes
Receipts:
Number of participants per day:
$10,000 per horse/$100,000 aggregate
$10,000 per horse/$50,000 aggregate
$5,000 per horse/$50,000 aggregate
$5,000 per horse/$25,000 aggregate
6/1/2016 8
1.
$
2.
$
$
Eff $
Disease
$
$
Policy#
$
Eff $
$
$
Policy#
$
Eff TO $ Each Occurrence
$ Per Occurrence
$ Aggregate
Eff
3. Does the applicant have any of the following exposures?:
4.
No
No
Uninsured/Underinsured Motorists Coverage (UM/UIM) is excluded on the Umbrella with the following
exceptions:
FL and WV:
Is UM/UIM coverage desired?
Yes
LA, NH and VT:
UM/UIM is included but the maximum selected Umbrella limit is $1,000,000.
Please provide copies of all non-Great American policies (A-rated carriers only)for which umbrella coverage is requested
$4,000,000
# of Medium Trucks:
# of Heavy Trucks:
Property Damage
If yes, the maximum selected Umbrella limit is $1,000,000.
Watercraft
Liability
Auto Details
(Not required if filling out a separate Auto Application and we will be the only Auto Carrier)
:
Policy#
TO
Limits
Each Accident
Each Policy
Each Employee by
Employer's
Liability
Are there any drivers under the age of 21?
Yes
$3,000,000
$5,000,000
General Aggregate
Products/Completed Ops
Personal & Advertising Injury
Umbrella Additional Underlying Policy Supplemental Attached
Great American
Great American
# of Private Passenger Vehicles:
Owned or Leased Aircraft
Migrant workers used in farming operations
Watercraft
# of Light Trucks:
# of Extra Heavy Truck Tractors:
# of Heavy Truck Tractors:
Great American
COVERAGE IS NOT DESIRED
# of Buses:
Combined Single Limit
Bodily Injury - Each Person
Bodily Injury - Each Accident
Custom Application of Farm Chemicals for Others
TO
Requested Limit of Insurance:
Schedule of Underlying Insurance
Company
Type of Coverage
$1,000,000
$2,000,000
UMBRELLA SECTION
General Liability
Farm
Commercial
Personal
Policy#
TO
N/A
Automobile
Liability
Personal
Commercial
Non-owned
Hired
Show evidence of proper maintenance
Continuous masonry foundation
May be open on one side
Insured to minimum of 80% of actual cash value or 60% of replacement cost
CLASS 2
Other buildings not eligible under Class 1 or Class 2
CLASS 3
Does not contain a second floor
No regular or continuous hay storage
Fully enclosed with no open shed attached
Insured to minimum 80% of replacement cost
Not used for livestock, poultry or other animal confinement
CLASS 1
OUTBUILDINGS
Building Class Building Characteristics
Show evidence of proper maintenance
Have an incombustible floor throughout (except for granaries and cribs)
Built on a continuous masonry foundation
Must not be mobile home or log construction more than 15 years of age
Insured to a minimum 80% actual cash value or 60% of replacement cost
CLASS 2
All mobile homes
Any dwellings not eligible under Class 1 or Class 2
All log homes over 15 years of age
CLASS 3
Evidence of proper maintenance and good housekeeping
Circuit Breakers (no fuses)
Thermostatically controlled heating
Continuous enclosed foundation (porches excepted)
Phone Service
Modern interior plumbing and electrical system (fuses acceptable)
Newer construction or remodeled inside and outside
Evidence of proper maintenance and good housekeeping
Continuous enclosed foundation
Phone Service
Must not be mobile home or log construction
Insured to 80% of replacement cost
BUILDING CLASS DEFINITIONS
Building Characteristics
Building Class
Owner or operator occupied
CLASS 1
DWELLINGS
8/4/16
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EQUINE FARM APPLICATION (Abram Interstate Insurance)

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Completed 10 July 2021

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