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OPERATIONS MUST BE DECLARED. ALL HORSE-RELATED EXPOSURES MUST (Risk Placement Services, Inc.)

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ORIGINAL APPLICATION MUST BE RETURNED PAGE 1
A4230.DOC-0201
AGENCY NAME CODE
ADDRESS
PHONE NUMBER FAX NUMBER
E-MAIL ADDRESS
APPLICATION FOR COMMERCIAL EQUINE LIABILITY
(A Special program Limited to Horse-Related Exposures Only)
THIS IS NOT A BINDER
IMPORTANT: INCOMPLETE AND UNSIGNED APPLICATIONS WILL BE RETURNED FOR COMPLETION. ALL
OPERATIONS MUST BE DECLARED. ALL HORSE-RELATED EXPOSURES MUST BE INSURED.
NEW BUSINESS – DESIRED EFFECTIVE DATE / / RENEWAL – EXPIRATION DATE / /
NAME OF APPLICANT BUSINESS/STABLE NAME
MAILING ADDRESS / CITY / STATE / ZIP CODE
TELEPHONE NUMBER
( )
PERSON TO CONTACT FOR INSPECTION
NOTICE – WHEN MORE THAN ONE APPLICANT (HUSBAND AND WIFE EXCEPTED), EXPLAIN INTEREST OF EACH
LOCATION(S) OF ACTUAL OPERATIONS – INDICATE IF APPLICANT OWNS OR LEASES PREMISES
Address (including zip code) Number of Acres Premises
1. Own Lease
2. Own Lease
APPLICANT IS
Individual Partnership Organization/Corporation Owner Operator Other (specify)
NAME OF ALL PARTNERS OR OFFICERS OF CORPORATION
CERTIFICATES OF INSURANCE REQUESTED FOR
Owner of Premises: Name
Address
Certificateholder Only Additional Insured
Other – Describe Interest:
Name and Address
Certificateholder Only Additional Insured, If Eligible
LIMITS OF LIABILITY – PLEASE CHECK ONLY ONE SET OF DESIRED LIMITS
$300,000 CSL/Occ. $500,000 CSL/Occ. $1,000,000 CSL/Occ. $ CSL/Occ.
$600,000 Agg. $1,000,000 Agg. $2,000,000 Agg. Other
INQUIRE ABOUT THE AVAILABILITY OF INCREASED LIMITS ON THE FOLLOWING OPTIONS:
General Aggregate Medical Payments Fire Legal Liability
DO YOU DESIRE COVERAGE FOR CARE, CUSTODY, OR CONTROL FOR NON-OWNED HORSES (IF YES, PLEASE
COMPLETE A SEPARATE APPLICATION - IF NO, PLEASE SIGN HERE AS HAVING REJECTED COVERAGE.) Yes No
APPLICANT
X
DATE
/ /
PAGE 2
A4230.DOC-0201
GENERAL INFORMATION & UNDERWRITING QUESTIONNAIRE
1.
DESCRIBE ALL FARMING OR HORSE-RELATED OPERATIONS
2.
NUMBER OF YEARS AT THIS LOCATION
NUMBER OF YEARS EXPERIENCE IN THESE OPERATIONS
3.
IF LESS THAN FIVE (5) YEARS, GIVE BRIEF DESCRIPTION OF EXPERIENCE AND BACKGROUND IN HORSE BUSINESS
4.
DO YOU HAVE WORKERS’ COMPENSATION INSURANCE
Yes No
Note: Workers’ Compensation
and Employer’s Liability is not
covered under this policy.
PAYROLL FOR HORSE OPERATIONS
$
5.
IS THIS YOUR PRINCIPAL OCCUPATION – IF NO, DESCRIBE OCCUPATION OR BUSINESS YOU ARE ENGAGED IN
Yes No
6.
ARE THERE ANY BUSINESS ENTERPRISES OR PROFESSIONAL OFFICES ON ANY OF THE DESCRIBED PREMISES – IF YES, PLEASE EXPLAIN
Yes No
7.
DO YOU LEASE ANY PART OF THE LAND, BUILDINGS, STABLES, STALL SPACE, OPERATIONS TO OTHERS – IF YES, PLEASE EXPLAIN
Yes No
8.
IS THERE 24-HOUR SUPERVISION OF THE FACILITY – IF YES, PLEASE DESCRIBE
Yes No
9.
ARE ALL PASTURES TOTALLY FENCED – DESCRIBE TYPE OF ALL FENCING
Yes No
10.
DESCRIBE CONDITION
Excellent Good Fair Poor
HOW OFTEN IS FENCING CHECKED
11.
WHO IS RESPONSIBLE FOR FENCE REPAIR
Owner Lessee
RIDING FACILITIES
Arena: Indoor Outdoor Open Fields Trails
12.
DO YOU HAVE OPERABLE FIRE EXTINGUISHERS VISIBLE AND READILY ACCESSIBLE IN
YOUR STABLES Yes No
IN OTHER OUTBUILDINGS/BARNS
Yes No
13.
DO YOU OBTAIN A RELEASE SIGNED BY BOARDERS AND STUDENTS RELIEVING YOU OF CLAIMS FOR BI & PD – IF YES, PLEASE ATTACH A COPY TO THIS APPLICATION
Yes No
14.
DO YOU POST RULES
Yes No
DO YOU POST WARNING SIGNS
Yes No
DESCRIBE ANY SAFETY PROGRAM OR ATTACH INFORMATION
15.
DO YOU OWN/MAINTAIN DOGS ON THE DESCRIBED PREMISES – IF YES, HOW MANY
Yes No
WHAT BREED
16.
HAS ANY DOG BITTEN OR CAUSED INJURY TO ANYONE – IF YES, PROVIDE DETAILS
Yes No
17.
DO YOU OWN/MAINTAIN ANY OTHER ANIMALS, OSTRICHES, EMUS, ETC. - IF YES, HOW MANY
Yes No
WHAT TYPE
18.
IS THERE A SWIMMING POOL ON THE PROPERTY
Yes No
IF YES, IS IT RESTRICTED TO PRIVATE USE
Yes No
19.
IS HUNTING/FISHING PERMITTED ON THE PROPERTY – IF YES, PLEASE EXPLAIN
Yes No
20.
DO YOU OPERATE A BED AND BREAKFAST – IF YES, PLEASE DESCRIBE
Yes No
PAGE 3
A4230.DOC-0201
SECTION I. SUMMARY OF HORSES – AT PEAK SEASON
ACCOUNT FOR EACH ANIMAL BELOW ONLY ONCE, BASED ON ITS PRIMARY USE
Horses Owned/Leased/Used by Insured: Number
1a. Owned horses used for instruction ........................................
b. Boarded horses used for instruction to others.......................
2. Show and/or pleasure.............................................................
3. Racing and/or training to race................................................
4. Breeding (Mares ,Stallions )............................
5. Foals/weanlings ......................................................................
6. Retired and/or lay-ups ............................................................
7. For sale (Breed ) .........................................................
8. Other (Describe: )........................................................
All Owned Horses Must be Declared
Total (Lines 1-8)
9. Number of carts, buggies, carriages, etc...............................
Describe Use:
Horses Non-Owned by Insured: Number
1. Boarding/pasturing.............................................................
2. Show training......................................................................
3. Racing and/or training to race............................................
4. Breeding (Mares , Stallions )......................
5. Foals/weanlings..................................................................
6. Retired and/or lay-ups........................................................
7. Consignment for sale (Breed )...............................
8. Other (Describe: )...................................................
Total (Lines 1-8)
9. Total number of stalls on your premises ...........................
10. What is the maximum number of horses, owned and
non-owned that can be kept on your premises?...............
SECTION II. HORSES NON-OWNED BOARDING, BREEDING, TRAINING, RACING CHECK IF NO EXPOSURE AND NITIAL
1.
TOTAL NUMBER OF STALLS
MAXIMUM NUMBER BOARDED
PASTURED
MONTHLY BOARDING RATE
$
ANNUAL GROSS
$
2.
TRAINING PLEASURE & SHOW: MAXIMUM NUMBER OF NON-OWNED HORSES IN TRAINING
MONTHLY TRAINING RATE
$
ANNUAL GROSS
$
3.
BREEDING: NUMBER OF NON-OWNED
STALLIONS
BREED
MAXIMUM NUMBER OF OUTSIDE MARES
ARE MARES KEPT ON PREMISE ‘TIL FOALING
4.
RACE HORSES: WHAT BREEDS
HOW MANY DO YOU TRAIN FOR OTHERS
PAYROLL
$
WHAT STATES DO YOU RACE IN
ARE YOU ACTIVELY INVOLVED IN THE RACING/TRAINING OF YOUR OWN RACE HORSES
Yes No
SECTION III. EQUESTRIAN SCHOOLS – RIDING INSTRUCTION – CLINICS CHECK IF NO EXPOSURE AND INITIAL
1.
IS INSTRUCTION PROVIDED BY
You An Independent Instructor
If an independent
instructor/trainer is used,
complete Section IV.
ARE YOU A CERTIFIED INSTRUCTOR
Yes No
2.
DESCRIBE TYPE OF SAFETY GEAR REQUIRED
3.
DO YOU PROVIDE RIDING FOR THE HANDICAPPED
Yes No
GROSS ANNUAL RECEIPTS
$
NON-PROFIT
Yes No
NUMBER OF HORSES AVAILABLE FOR HANDICAPPED
RATIO OF INSTRUCTORS TO STUDENTS
ARE SIDEWALKERS USED
VOLUNTEER COVERAGE REQUESTED
Yes No
4.
MAXIMUM NUMBER OF SCHOOL HORSES AVAILABLE
MAXIMUM NUMBER USED AT ANY ONE TIME
GROSS ANNUAL RECEIPTS
$
5.
ARE STALLIONS USED FOR INSTRUCTION
Yes No
IF SO, INDICATE THE LEVEL OF THE RIDER AND AGE
6.
DO YOU GIVE INSTRUCTION TO STUDENTS ON
THEIR OWN HORSES Yes No
IF SO, ADVISE AVERAGE NUMBER OF LESSONS PER WEEK
ANNUAL GROSS RECEIPTS
$
7.
DO YOU TEACH
English Jumping Saddle Seat Western Dressage Other:
8.
IS THERE ANY PERIOD OF THE YEAR DURING WHICH YOU DO NOT GIVE INSTRUCTIONS – IF SO, GIVE DATES CLOSED
Yes No
PAGE 4
A4230.DOC-0201
SECTION III. continued CHECK IF NO EXPOSURE AND INITIAL
9.
DO YOU ATTEND OFF-PREMISES SHOWS WITH YOUR STUDENTS
Yes No
Injuries to horses and
students being transported
are not covered.
HOW MANY TIMES PER YEAR
GROSS RECEIPTS
$
10.
DO YOU HOLD CLINICS FOR NON-STUDENTS
Yes No
HOW MANY DAYS
AVERAGE ATTENDANCE
RECEIPTS EARNED
$
11.
DO YOU OPERATE A DAY CAMP
Yes No
OVERNIGHT CAMP
Yes No
DO YOU PROVIDE FOOD
Yes No
GROSS RECEIPTS FOR CAMP
$
12.
DESCRIBE ALL ACTIVITIES OFFERED AT CAMPS OTHER THAN RIDING INSTRUCTIONS
SECTION IV. INDEPENDENT INSTRUCTORS / TRAINERS CHECK IF NO EXPOSURE AND INITIAL
1.
DO INDEPENDENT TRAINERS OR INSTRUCTORS OPERATE ON YOUR PREMISES – IF SO, HOW MANY
Yes No
DO THEY CARRY THEIR OWN INSURANCE++
Yes No
++ If so, we will require a copy of a Certificate of Insurance for each insured for coverage with limits equal to those you carry.
We will also require that they name you as an additional insured under their policy. If the independent instructors or trainers
DO NOT carry their own insurance, they will be added as an insured for an additional charge if eligible. Coverage is limited to
on-premises only and to off-premise shows with horses and/or riders in training.
PROVIDE NAMES OF INDEPENDENT INSTRUCTORS OR TRAINERS AND ADDRESSES (MUST BE 18 YEARS OF AGE OR OLDER)
INDEPENDENTS COVERED ON THIS POLICY MUST USE A RELEASE. ATTACH COPY(IES).
2.
HOW MANY HORSES ARE PROVIDED FOR LESSONS BY
INDEPENDENT INSTRUCTORS
GROSS RECEIPTS
$
GROSS RECEIPTS FOR INSTRUCTION TO STUDENTS
ON THEIR OWN HORSES $
3.
HOW MANY OF YOUR BOARDED HORSES ARE BEING TRAINED BY INDEPENDENT TRAINERS
OR TRAINED UNDER YOUR NAME
SECTION V. PONY RIDES / SADDLE ANIMALS FOR HIRE / HOURLY OR DAILY RENTALS / CHECK IF NO EXPOSURE AND INITIAL
TRAIL RIDES / LEASING / PACK TRIPS
1.
NUMBER OF ANIMALS AVAILABLE FOR
RENTAL OR TRAIL RIDES
GROSS RECEIPTS FOR RENTALS
$
GROSS RECEIPTS FOR TRAIL RIDES
$
DO YOU CONDUCT PACK TRIPS
Yes No
2.
PONY RIDES/PARTIES: NUMBER OF PONIES
GROSS RECEIPTS
$
DO YOU USE SIDEWALKERS
Yes No
3.
DO YOU RENT OR LEASE HORSES OR PONIES TO CAMPS/RESORTS OR INDIVIDUALS – IF SO, HOW MANY – PLEASE EXPLAIN
Yes No
SECTION VI. SALES – HORSE, FOOD, CLOTHING, TACK, FEED, HORSESHOEING CHECK IF NO EXPOSURE AND INITIAL
1.
DO YOU SELL HORSES
Yes No
WHAT BREEDS
HOW MANY PER YEAR
GROSS ANNUAL RECEIPTS
$
2.
IS BUYER ALLOWED TO TEST RIDE
Yes No
IF YES
In arena In open field
DO YOU SELL FROM YOUR OWN PREMISES
Yes No
3.
EXPLAIN ANY OTHER METHOD OF SALES
4.
DO YOU SELL FOOD OR HAVE A SNACK BAR
Yes No
Liquor liability not
covered.
GROSS RECEIPTS
$
5.
DO YOU SELL TACK AND/OR CLOTHING – IF YES, USED OR NEW
Yes No Used New
GROSS RECEIPTS
$
6.
DO YOU SELL HAY OR FEED
Yes No
GROSS RECEIPTS
$
7.
DO YOU MIX FEED FOR SALE/CONSUMPTION
Yes No
8.
DO YOU REPAIR RIDING EQUIPMENT FOR OTHERS
Yes No
9.
DO YOU PERFORM ANY TYPE OF FARRIER SERVICES
Yes No
Injury to horse
not covered.
ARE SERVICES ON PREMISE ONLY
Yes No
GROSS RECEIPTS
$
If on premises only,
this coverage can be
added to this policy.
NOTE: Products liability for any and all exposures involving sale or horses or other livestock, repair of tack, sale of feed if mixed or
prepared by the insured is excluded from coverage.
IMPORTANT – ORIGINAL APPLICATION MUST BE RETURNED
INSURED’S SIGNATURE IS REQUIRED TO PROVIDE A FIRM QUOTE AND IN ORDER TO BIND COVERAGE
PAGE 5
A4230.DOC-0201
SECTION VII. RIDES, HORSE SHOWS AND MISCELLANEOUS ACTIVITIES CHECK IF NO EXPOSURE AND INITIAL
1.
NUMBER OF
PASSENGERS
GROSS
RECEIPTS
NUMBER OF
WAGONS
NUMBER OF
HORSES
NUMBER OF
MOTOR VEH
NUMBER OF
TRIPS
ON OR OFF
PREMISES
RIDES
HAY
SLEIGH
CARRIAGE
$
2.
DO YOU MANAGE ANY SHOWS OPEN TO BOARDERS OR NON-STUDENTS
Yes No
ARE THESE SHOWS RECOGNIZED BY THE AMERICAN HORSE SHOW ASSOC.
Yes No
NUMBER OF
PARTICIPANTS
GROSS RECEIPTS
(ALL SHOWS)
MAXIMUM NUMBER OF
SPECTATORS PER DAY
TOTAL NUMBER OF
SHOW DAYS
SHOW DATES
$
SHOWS
Independent vendors
are not covered.
SHOWS
ON PREMISES
RODEOS
ON PREMISES
$
3.
DO YOU SECURE RELEASES FROM ALL ENTRANTS – ATTACH SAMPLE
Yes No
DOES NUMBER OF SPECTATORS EVER EXCEED 500 PER DAY
Yes No
4.
DO YOU HAVE BLEACHERS OR GRANDSTANDS
Yes No
CONSTRUCTION
YEAR BUILT
SEATING CAPACITY – NUMBER
5.
DO YOU MANAGE ANY HUNTS OR RACING EVENTS
Yes No
IF YES, WHAT TYPE DO YOU OWN/USE/LEASE ANY HOUNDS FOR HUNTS
Yes No
HOW MANY HOUNDS
6.
IF RODEOS ON PREMISE, DESCRIBE TYPE OF EVENTS
7.
DO YOU ALLOW NON-BOARDERS TO USE YOUR FACILITIES. IF YES, PLEASE EXPLAIN.
Yes No
8.
ALL OPERATIONS MUST BE DECLARED - DESCRIBE FULLY ANY OTHER EVENTS OR OPERATIONS NOT ALREADY MENTIONED IN THIS APPLICATION
NOTE: Coverage is not provided for injury to participants in horse races, rodeos, rodeo-type events, hunts, vaulting, and polo
matches/practice.
PREVIOUS 3 YEARS CARRIER INFORMATION REQUIRED (IF NO PREVIOUS CARRIER, STATE NONE)
COMPANY
POLICY
NUMBER
POLICY
PERIOD
PREMIUM
NUMBER OF
CLAIMS
LOSSES AND
RESERVES
1.
HAVE YOU HAD ANY LOSSES IN THE PAST FIVE (5) YEARS – IF YES, GIVE APPROXIMATE DATES AND EXPLANATIONS INCLUDING PAYMENTS MADE
Yes No
2.
HAVE YOU BEEN CANCELLED OR DENIED COVERAGE IN THE LAST THREE (3) YEARS – IF YES, PLEASE EXPLAIN
Yes No
3.
IS THIS BUSINESS BROKERED – IF YES, BROKER IS TO PROVIDE NAME, ADDRESS, CITY, STATE, ZIP CODE AND TELEPHONE NUMBER
Yes No
STANDARD FRAUD WARNING: 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 may subject such person to
criminal and substantial civil penalties. (This wording does not apply in Oregon.)
FLORIDA: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is guilty of
insurance fraud and is subject to criminal and civil penalties.
VIRGINIA: 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 undersigned hereby applies for insurance coverage as set forth in the application and affirms that the statements and representations
made are to be best of his/her knowledge true.
APPLICANT’S SIGNATURE
x
DATE
/
/
AGENT’S SIGNATURE
X
DATE
/
/
PAGE 6
A4230.DOC-0201
You may use this page to supplement your application with any additional information.
THANK YOU!
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OPERATIONS MUST BE DECLARED. ALL HORSE-RELATED EXPOSURES MUST (Risk Placement Services, Inc.)

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Completed 30 July 2020

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