Fillable Equine Supplemental Application Do you require all clients (Risk Placement Services, Inc.)

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Equine Supplemental Application Do you require all clients (Risk Placement Services, Inc.)

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1
Equine Supplemental Application
Name: _____
___________________________ Website : www.________________________ Years
in Equine business: _________________ Equine Associations (member): __________________
Describe your Equine operation: ___________________________________________________________
Applicant’s Exposure –
• Number of horses you own or lease for your own use? _______
• How many are used for :
Pleasure riding? ____ Showing? ____ Instruction? ____ Sales prep? ____ •
• Are they all stabled on your premises? Yes No If No, where? ________________________
• Do you sell any horses? Yes No If Yes, how many? _____ Annual Sales? ______________
Far
ey filed and maintained? Yes No Provide a copy
• o
hile on your
_________
o
•
If Yes, explain ________________________________________________________________
________________
oa
•
nsed o
h h
orse being
h animal? _____________________________
___ Maximum number of boarded horses pastured? ______
_________________
•
m Premises Exposure –
• Do you require all clients to sign a Hold Harmless agreement, are th
• Is there 24 hour supervision of the farm premises? Yes No
• Are Emergency Phone Numbers clearly posted? Yes No
• Are Safety and Barn Rules clearly posted? Yes No Provide a copy
• Are “No Smoking” signs clearly posted throughout the farm premises? Yes No
• Is alcohol consumption allowed on the premises? Yes No If Yes, explain ___________
Are the State Equine Liability Warning signs posted throughout the farm premises? Yes N
• Do you require all individuals under the age of 18 to wear an approved safety helmet at all times w
premises? Yes No If
No, explain ___________________________________________
• Are all fences/gates in good condition? Yes No How often are they checked?_________
• Yes Any barbed wire allowed for fencing? No If Yes, explain ____________________
• Any wire fencing used on the premises? Yes No If Yes, explain __________________
• What type of perimeter fencing is used? _____________________________________________
• Has any animal ever escaped? Yes No If Yes, explain _________________
• Do you have dogs on the premises? Yes No If Yes, Breed? _______________________
• Do you allow your clients to bring their dogs? Yes No If Yes, on leashes? Yes N
• Do you sell any tack or clothing? Yes No If Yes, annual receipts? ______
• Do you repair any tack or riding equipment? Yes No If Yes, explain ______________
• Do you provide any type of farrier services? Yes No If Yes, explain ______________
Do you provide, prepare any type of feed for sale to the general public? Yes N
o
• How do you dispose of the animal waste? __________________________
• ro erAre all outdoor electrical outlets installed with waterproof / dust p of cov s? Yes No
If No, explain _________________________________________________________________
B rding Operations (Non Owned Horse
s being stabled) – Not Applicable
• Do you provide riding facilities for your clients? Yes No If Yes, explain ____________
Do you require all boarders to sign a Hold Harmless agreement? Yes No Provide a copy
______________________________If No, explain _____________________________________
• Do you require Certificates of Health from a lice veterinarian for each horse being boarded? Yes N
If No, explain __________________________________________________________________
• Do you require some type of written identification description, or permanent identification for eac
boarded? Yes No If No, how will you
distinguish eac
• Number of stalls on premises used for boarding? ______
• Maximum number of horses boarded? ___
• Do you allow temporary overnight boarding of horses? Yes No If Yes, number? ______
• Is boarding self board or full care? ________________________________
• Annual Receipts for all boarding operations? ___________
Annual Payroll for all boarding operations? __________
Equine Supplemental Application
2
orse T
_________________
?
nce? Yes No Provide a copy
me you as an Additional Insured.
No Provide a copy
erations? _______
s? _______
r year? _______
Bre n
•
re the annual receipts? ______
nce
s? _______
o
Hor S
ises? Yes No Off premises? Yes No
• h
• h ______
• ______
_________________
• ovide a copy
___ _
• If Yes, what is the construction of the bleachers or grandstands? ______________________
• If Yes, what is the height of the bleachers or grandstands? ____________
• If Yes, what is the seating capacity? ___________
No
___________
•
_______________________
ities? Yes No
• okups? _______
H raining Operations – Not Applicable
• What type of training is performed? _______________________________
• Is the Trainer – You? Employee? Independent contractor
• If an independent contractor, do you require a Certificate of Insura
The Certificate of Insurance must na
• Do you require a contractual agreement between you and the owner of horse in training? Yes
_____________________________________ If No, explain ____________________________
• What is the total annual payroll from the training op
• What are the annual receipts from the training operation
• What is the average number of horses trained pe
edi g Operations - Not Applicable
• Do you manage stallions ? Yes No If Yes, how many? _________________________
• How many stallions are owned by you? ______
• How many stallions are owned by others? ______
• Do you manage or keep broodmares ? Yes No
How many broodmares do you own? ______
• How many non-owned broodmares do you allow on your premises at any one time? ______
• Do you offer foaling services? Yes No If Yes, what a
• Do you provide or have a veterinarian on staff? Yes No If Yes, provide a copy of a Certificate of Insura
showing the placement of Professional Liability, as we exclude this coverage.
• What are the annual receipts from the breeding operations? _______
• What is your annual payroll from the breeding operation
• Do you require Certificates of Health from a licensed veterinarian for each horse being bred? Yes N
If No, explain __________________________________________________________________
• Do you require some type of permanent identification for each horse being bred? Yes No
se hows/Activities “On Your Premises” – Not Applicable
• Do you sponsor any horse shows/activities on your prem
W at are the numbers of spectators per day/show? ______ Total per show? ______
W at are the numbers of participants per day/show? ______ Total per show?
• What are the total receipts per show/activities? ______
Dates of the shows/activities? ______________________________________________________
• Types of shows/activities? ______________________________________________
Do you obtain Waivers and Hold Harmless agreements from each participant
? Yes No Pr
If No, explain ________________________________________________________________ ___
• mAre the shows/activity sanctioned? Yes No If Yes, by who ? __________________________
• Do you have bleachers or grandstands? Yes No
• Do you provide concession during these shows? Yes
If Yes, explain ______________________________________________________
Do you allow vendors on the premises during the shows/activities? Yes No
If Yes, explain the type of items sold? _______________________
If Yes, do you obtain Certificates of Insurance from each vendor?
Yes No
• Do you provide Emergency Medical Care or an EMT during your shows/activ
Do you allow RV or camper hookups during the shows/activities? Yes No
If Yes, # of ho
What are the annual receipts from this activity? ________
Equine Supplemental Application
3
Horse Show c
• Do you
If Y
Do you sing your facility? Yes No
• Do you
If Y
Hor A
•
t a single event? ______
nual amount _______
________________
•
__
sported? ________
Rid I
ing? Other? (explain) ________________
______________________
• Independent contractor?
s of experience - You? ____ Employee? ____ Independent contractor? ____
• s
• Is e ___
• an Yes No Provide a copy
e
• What is the total annual payroll from the riding instruction operations? _______
• What are the annual receipts from the riding instruction operations? _______
mber of students given instruction per week? _______
•
Yes No If Yes, is all
__________________
• Do you require all students to wear safety stirrups? Yes No
• Do you require all beginning student to use lunge lines? Yes No
• Do you require all students to use a bridle and bit, instead of halters? Yes No
• Do you maintain a log and document all incidents involving injury or accident involving your students? Yes No
• Do you provide any night riding instruction? Yes No If Yes, is there adequate lighting? Yes No
s/A tivities “On Your Premises” –
(continued)
lease your facility to other to hold shows and events? Yes No
e
s, explain ________________________________________________________________
What are the annual receipts from leasing your
facility?
________
obtain a Certificate of Insurance from the pe
rson(s) lea
allow any other type of activities on your premises? Yes No
e
s, explain _________________________________________________________________
se ctivities “Away From Your Premises” – Not Applicable
Do you attend h
orse events/activities away from your premises?
• With your own horses? Yes No
• If Yes, how many horses a
• If Yes, how many events do you attend on an annual basis? _______
• If Yes, what type of events do you attend? _________________________________
• If Yes, do you receive any remuneration/money? Yes No If Yes, an
• With horses in your Care, Custody or Control? Yes No
• orIf Yes, how many h ses at a single event? ______
• If Yes, how many events do you attend on an annual basis? _______
• If Yes, what type of events do you attend? _________________
• If Yes, do you receive any remuneration/money? Yes No If Yes, annual amount _______
Do you transport horses to any of these events? Yes No If Yes, how many horses? _______
If Y
es, describe the vehicle and trailer _______________________________________________
If Yes, what is the per horse value? ________ Total value of all horses being tran
ing nstructions – Not Applicable
• Do you teach: English? Western? Jump
• Describe all Riding Instruction Operations - _________________________
Is the Riding Instructor – You? Employee?
• Describe the year
De cribe the qualifications _____________________________________________________________
ach instructor certified?
Yes No If No, explain ________________________________
If independent contractor, do you require a Certificate of Insurance?
Th
Certificate of Insurance must name you as an Additional Insured.
• d each student
(and parent if under 18 years)? Yes No Provide a copy
Do you require a Waiver, Hold Harmless and Medical Release agreements between you an
If No, explain _________________________________________________________________
• What is the average nu
• What is the minimum age of the students’? ______
• Do you attend off premises events with your students? Yes No
• If Yes, what are the numbers of events? ______
• If Yes, what are the annual receipts? _________
Student Safety –
• Do you require all students to wear safety helmets, long pants and boots?
equipment supplied by the student? Yes No I
f No, explain ___
Equine Supplemental Application
4
Clinics – Not Applicable
• Do you hold/sponsor clinics for non-students on your premises? Yes No Off Premises? Yes No
If Yes, describe ________________________________________________________________
• Number and Type of Clinics: _____________________________________________________
• Number of days per Clinic: _______ Average Attendance: _________
• Do you rent or lease your premises to others to hold clinics? Yes No If Yes, do you require a Certificate of
Insurance from each person naming you as an Additional Insured? Yes No
• Do you require outside clinicians to provide proof of insurance? Yes No
• What are the annual receipts from the clinics? _______________
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Completed 30 July 2020

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