RON ROTHERT INSURANCE SERVICES

RON ROTHERT INSURANCE SERVICES
FARM
Portland: (800) 452-7726
Seattle: (800) 800-6524
www.ronrothert.com
Did you know…..
At Ron Rothert Insurance Services we have several
farm markets.
We also have an underwriter in our Portland office
who specializes in this type of business.
We are the most successful on those risks that are
equine- related, but can certainly take a look at other
farm risks.
For more information, please see the following
documents. You may also call or e-mail Nicole Hill at
(800)452-7726 or [email protected].
TABLE OF CONTENTS
(To go directly to a specific page, just click on that page number)
Page 1-6: Overview of Farmowners/Stableowners Policy
Page 7- Equine Liability Application (Can be filled out
on-line)
Page 8- Our Carriers and Best Guide Ratings
Farmowners/Stableowners Policy
American Bankers
Insurance Company of Florida
High Level of Trust, Industry Expertise and Unwavering Commitment
The Farmowners/Stableowners Policy can cover the Dwelling(s), Contents, Outbuilding(s) Scheduled Farm Personal
Property, Blanket Farm Personal Property and Liability limits up to $1,000,000 all in one package policy. We routinely
offer Property limits up to $4,000,000 with availability for higher limits upon approval. Several deductible options are
available in addition to your choice of Perils: Basic, Broad or Special.
Dwelling
Blanket Farm Personal Property
Household Personal Property (Contents)
Farm Structures and Outbuildings
Inland Marine
Farm Liability
Scheduled Farm Personal Property
Coverages Include:
New construction of Farm Buildings (Basic Perils excluding theft) (60 days up to $50,000)
Pollutant clean up and removal (up to $10,000) Cab Glass on Mobile Machinery
Newly acquired machinery (30 days up to $50,000) Fire Legal Liability (up to $50,000)
Custom Farming (up to $5,000 in receipts)
Optional Coverages:
Additional (Optional) Perils – Livestock Commercial Equine Liability
Replacement Cost – Household Personal Property Limited Business Pursuits Liability
Care, Custody or Control Ordinance & Law Coverage
Employers Liability (not available in all states)
Recreational Vehicles or Watercraft
Earthquake on Dwelling(s) &/or Outbuilding(s)
Broad or Special on Structures or Outbuilding(s) including Collapse
The coverages described in this brochure are summarized and subject to the terms, conditions and exclusion printed in the policy. Refer to the policy
form for specifics on coverages and limits. Also, all coverages are subject to state law, which may vary materially from stated information. In providing
this material, Assurant Specialty Property and/or affiliates and subsidiaries assumes no liability beyond that provided under the terms, limits and
conditions of the insurance policies it has issued. This program may not be approved in every state.
M BR 8003 0407
Farmowners Policy
American Bankers
Insurance Company of Florida
High Level of Trust, Industry Expertise and Unwavering Commitment
The Farmowners Policy can cover the Dwelling(s), Contents, Outbuilding(s) Scheduled Farm Personal Property, Blanket
Farm Personal Property and Liability limits up to $1,000,000 all in one package policy. We routinely offer Property limits
up to $4,000,000 with availability for higher limits upon approval. Several deductible options are available in addition to
your choice of Perils: Basic, Broad or Special.
Dwelling
Blanket Farm Personal Property
Household Personal Property (Contents)
Farm Structures and Outbuildings
Inland Marine
Farm Liability
Scheduled Farm Personal Property
Coverages Include:
Pollutant clean up and removal (up to $10,000) Damage to Property of Others ($500)
Newly acquired machinery (30 days up to $50,000) Custom Farming (up to $5,000 in receipts)
New construction of Farm Buildings (Basic Perils excluding theft) (60 days up to $50,000)
Optional Coverages:
Additional Perils – Livestock Private Saddle Animals Liability
Replacement Cost – Household Personal Property Limited Business Pursuits Liability
Care, Custody or Control Expanded Debris Removal
Employers Liability (not available in all states)
Recreational Vehicles or Watercraft
Earthquake on Dwelling(s) &/or Outbuilding(s)
Ordinance & Law Coverage
Personal Liability Actual Cash Value
Replacement Cost on Outbuildings
Broad or Special on Structures or Outbuilding(s) including Collapse
The coverages described in this brochure are summarized and subject to the terms, conditions and exclusion printed in the policy. Refer to the policy
form for specifics on coverages and limits. Also, all coverages are subject to state law, which may vary materially from stated information. In providing
this material, Assurant Specialty Property and/or affiliates and subsidiaries assumes no liability beyond that provided under the terms, limits and
conditions of the insurance policies it has issued. This program may not be approved in every state.
M BR 8003 0407
Stable Liability Policy
American Bankers
Insurance Company of Florida
High Level of Trust, Industry Expertise and Unwavering Commitment
The protection you need for commercial stable activities are vital for stable owners, trainers, instructors and for others in
the equine business. Examples include but are not limited to:
Boarding
Private Lessons
Breeding
Riding Academies
Clinics
Riding Clubs
Horse Events (Sales and Shows)
These activities and their varied functions pose unique liability exposures, which need specially designed products
tailored to these exposures. The American Bankers Insurance Company of Florida Stable Liability Policy has the
flexibility to be custom tailored to cover the unique liability exposures that may not be adequately covered under normal
personal liability policies such as a homeowner policy or a farm liability policy
The policy will pay up to the limit of insurance, all sums which you become legally obligated to pay as damages due to
Bodily Injury or Property Damage to which coverage applies. Coverage is provided on an annual basis or for short-term
protection for horse shows, sales and clinics.
Stable Liability Coverages
Product Liability
Fire Legal Liability for $50,000.
Liability for personal and advertising injury
Liability limits available up to $1 million.
Basic and comprehensive liability coverage
for bodily injury and property damage to others.
Optional Care, Custody or Control
The coverages described in this brochure are summarized and subject to the terms, conditions and exclusion printed in the policy. Refer to the policy
form for specifics on coverages and limits. Also, all coverages are subject to state law, which may vary materially from stated information. In providing
this material, Assurant Specialty Property and/or affiliates and subsidiaries assumes no liability beyond that provided under the terms, limits and
conditions of the insurance policies it has issued. This program may not be approved in every state.
M BR 8003 0407
Farm/Ranch Umbrella Policy
American Bankers
Insurance Company of Florida
High Level of Trust, Industry Expertise and Unwavering Commitment
Liability Catastrophe Coverage
Farm Umbrella Insurance is a valuable coverage to provide higher liability limits than your primary policies: Farm
Personal, and/or Commercial Liability, Commercial Farm Auto and Other Underlying Insurance. The Farm Umbrella is
available to individuals, partnerships or other organizations for which American Bankers Insurance Company of Florida
writes the underlying insurance. You can now protect your assets with comprehensive and flexible coverage from one of
the leaders in Equine Insurance.
Coverage
The policy covers the insured’s liability for damages due to bodily injury sustained by another and property damage to
tangible property of others that arise out of the insured premises and the personal, farming and commercial farm or stable
activities and related operations of the insured.
Minimum limits of liability of underlying policies must be $500,000 Combined Single Limit and the underlying carriers
must have an A.M. Best rating of “A-” or better. The Farmowners/Stableowners, Stable Liability or Farmowners policy
must be written with American Bankers Insurance Company of Florida on the underlying Farm risk. The policy also
contains a drop down feature that would provide primary coverage in certain situations. This would apply after insured
paid the first $5,000 shown on the policy as self-insured retention.
The coverages described in this brochure are summarized and subject to the terms, conditions and exclusion printed in the policy. Refer to the policy
form for specifics on coverages and limits. Also, all coverages are subject to state law, which may vary materially from stated information. In providing
this material, Assurant Specialty Property and/or affiliates and subsidiaries assumes no liability beyond that provided under the terms, limits and
conditions of the insurance policies it has issued. This program may not be approved in every state.
M BR 8003 0407
Care, Custody or Control Policy
American Bankers
Insurance Company of Florida
High Level of Trust, Industry Expertise and Unwavering Commitment
The Equine Care, Custody or Control insurance is an essential coverage for all horse operations which involve non-owned
horses, including boarding, breeding and training. A Standard General Liability Insurance Policy excludes coverage for
personal property (horses are an example) in your Care, Custody or Control. This coverage fills this void by promising
to pay all sums you are legally obligated to pay for damage to non-owned horses in your Care, Custody or Control. This
coverage does not apply to horses that you own or lease.
Your policy will cover up to the chosen policy limits for the injury, theft or death of the horses in your Care, Custody or
Control. Policy limits are available up to $500,000 per horse and $1,000,000 maximum loss per policy year.
With Care, Custody or Control, you are protected against: Legal liability resulting from injury to or death of non-owned
horses in your care, custody or control and the cost to defend any suit alleging injury to or death of nonowned horses in
your care, custody or control.
You are eligible for this program if you own or lease a farm that boards horses belonging to others and your farm
employs a normal standard of care (normal standard of care includes but is not limited to 24-hour supervision, proper
maintenance, adequate and safe construction). You may also be eligible for this program if you operate a horse boarding
or training facility as an independent contractor.
The coverages described in this brochure are summarized and subject to the terms, conditions and exclusion printed in the policy. Refer to the policy
form for specifics on coverages and limits. Also, all coverages are subject to state law, which may vary materially from stated information. In providing
this material, Assurant Specialty Property and/or affiliates and subsidiaries assumes no liability beyond that provided under the terms, limits and
conditions of the insurance policies it has issued. This program may not be approved in every state.
M BR 8003 0407
Equipment Tack Floater Policy
American Bankers
Insurance Company of Florida
High Level of Trust, Industry Expertise and Unwavering Commitment
The Equipment Tack Floater policy provides Named Peril Coverage for tack and other horse-related items. Rates are
based on 3% of the value of the tack which includes saddles, bridles, bits and other riding equipment with a minimum
premium of $75. No deductible applies. Territories include the United States and Canada. This coverage is written as a
monoline policy.
Covered perils are: theft, smoke, windstorm, tornado, earthquake, explosion, riot/civil commotion, fire, lightning,
collapse of bridge or culverts, hail, flood and objects falling from aircraft.
The coverages described in this brochure are summarized and subject to the terms, conditions and exclusion printed in the policy. Refer to the policy
form for specifics on coverages and limits. Also, all coverages are subject to state law, which may vary materially from stated information. In providing
this material, Assurant Specialty Property and/or affiliates and subsidiaries assumes no liability beyond that provided under the terms, limits and
conditions of the insurance policies it has issued. This program may not be approved in every state.
M BR 8003 0407
AGENCY NAME
CODE
ADDRESS
PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
APPLICATION FOR COMMERCIAL EQUINE LIABILITY
PLEASE SEND COMPLETED APPLICATION TO NICOLE HILL AT [email protected]
PHONE: 503-252-5454 OR 800-452-7726 EXT. 235
FAX: 503-252-4048 OR 800-473-8731
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
/
/
NAME OF APPLICANT
RENEWAL – EXPIRATION DATE
/
/
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.
$600,000 Agg.
$500,000 CSL/Occ.
$1,000,000 Agg.
$1,000,000 CSL/Occ.
$2,000,000 Agg.
$
Other
CSL/Occ.
INQUIRE ABOUT THE AVAILABILITY OF INCREASED LIMITS ON THE FOLLOWING OPTIONS:
General Aggregate
Medical Payments
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.)
APPLICANT
Fire Legal Liability
Yes
No
DATE
/
X
ORIGINAL APPLICATION MUST BE RETURNED
/
PAGE 1
A4230.DOC-0201
GENERAL INFORMATION & UNDERWRITING QUESTIONNAIRE
1.
2.
3.
DESCRIBE ALL FARMING OR HORSE-RELATED OPERATIONS
NUMBER OF YEARS AT THIS LOCATION
NUMBER OF YEARS EXPERIENCE IN THESE OPERATIONS
IF LESS THAN FIVE (5) YEARS, GIVE BRIEF DESCRIPTION OF EXPERIENCE AND BACKGROUND IN HORSE BUSINESS
DO YOU HAVE WORKERS’ COMPENSATION INSURANCE
4.
5.
6.
7.
8.
9.
10.
11.
Yes
No
Note: Workers’ Compensation PAYROLL FOR HORSE OPERATIONS
and Employer’s Liability is not
$
covered under this policy.
IS THIS YOUR PRINCIPAL OCCUPATION – IF NO, DESCRIBE OCCUPATION OR BUSINESS YOU ARE ENGAGED IN
Yes
No
ARE THERE ANY BUSINESS ENTERPRISES OR PROFESSIONAL OFFICES ON ANY OF THE DESCRIBED PREMISES – IF YES, PLEASE EXPLAIN
Yes
No
DO YOU LEASE ANY PART OF THE LAND, BUILDINGS, STABLES, STALL SPACE, OPERATIONS TO OTHERS – IF YES, PLEASE EXPLAIN
Yes
No
IS THERE 24-HOUR SUPERVISION OF THE FACILITY – IF YES, PLEASE DESCRIBE
Yes
No
ARE ALL PASTURES TOTALLY FENCED – DESCRIBE TYPE OF ALL FENCING
Yes
No
DESCRIBE CONDITION
Excellent
HOW OFTEN IS FENCING CHECKED
Good
Fair
Poor
WHO IS RESPONSIBLE FOR FENCE REPAIR
Owner
RIDING FACILITIES
Lessee
Arena:
DO YOU HAVE OPERABLE FIRE EXTINGUISHERS VISIBLE AND READILY ACCESSIBLE IN
12. YOUR STABLES
Yes
No
13.
14.
15.
16.
18.
19.
20.
Outdoor
Open Fields
Trails
Yes
No
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
DO YOU POST RULES
Yes
No
DO YOU POST WARNING SIGNS
Yes
DO YOU OWN/MAINTAIN DOGS ON THE DESCRIBED PREMISES – IF YES, HOW MANY
Yes
DESCRIBE ANY SAFETY PROGRAM OR ATTACH INFORMATION
No
WHAT BREED
No
HAS ANY DOG BITTEN OR CAUSED INJURY TO ANYONE – IF YES, PROVIDE DETAILS
Yes
No
DO YOU OWN/MAINTAIN ANY OTHER ANIMALS, OSTRICHES, EMUS, ETC. - IF YES, HOW MANY
17.
Indoor
IN OTHER OUTBUILDINGS/BARNS
Yes
IS THERE A SWIMMING POOL ON THE PROPERTY
Yes
WHAT TYPE
No
No
IF YES, IS IT RESTRICTED TO PRIVATE USE
Yes
No
IS HUNTING/FISHING PERMITTED ON THE PROPERTY – IF YES, PLEASE EXPLAIN
Yes
No
DO YOU OPERATE A BED AND BREAKFAST – IF YES, PLEASE DESCRIBE
Yes
No
PAGE 2
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
Horses Non-Owned by Insured:
1a. Owned horses used for instruction ......................................
1. Boarding/pasturing............................................................
b. Boarded horses used for instruction to others ......................
2. Show training ....................................................................
2. Show and/or pleasure ...........................................................
3. Racing and/or training to race...........................................
3. Racing and/or training to race...............................................
,Stallions
4. Breeding (Mares
4. Breeding (Mares
) ...........................
8. Other (Describe:
) ......................................................
)......................
6. Retired and/or lay-ups ......................................................
6. Retired and/or lay-ups...........................................................
)........................................................
, Stallions
5. Foals/weanlings ................................................................
5. Foals/weanlings ....................................................................
7. For sale (Breed
Number
) ..............................
7. Consignment for sale (Breed
8. Other (Describe:
) ..................................................
Total (Lines 1-8)
All Owned Horses Must be Declared
Total (Lines 1-8)
9. Total number of stalls on your premises...........................
9. Number of carts, buggies, carriages, etc. .............................
Describe Use:
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
1.
2.
3.
4.
TOTAL NUMBER OF STALLS
MAXIMUM NUMBER BOARDED
CHECK IF NO EXPOSURE AND NITIAL
MONTHLY BOARDING RATE
ANNUAL GROSS
PASTURED
$
TRAINING PLEASURE & SHOW: MAXIMUM NUMBER OF NON-OWNED HORSES IN TRAINING
ANNUAL GROSS
$
$
MAXIMUM NUMBER OF OUTSIDE MARES ARE MARES KEPT ON PREMISE ‘TIL FOALING
BREEDING: NUMBER OF NON-OWNED BREED
STALLIONS
RACE HORSES: WHAT BREEDS
$
MONTHLY TRAINING RATE
WHAT STATES DO YOU RACE IN
HOW MANY DO YOU TRAIN FOR OTHERS PAYROLL
$
ARE YOU ACTIVELY INVOLVED IN THE RACING/TRAINING OF YOUR OWN RACE HORSES
Yes
No
SECTION III. EQUESTRIAN SCHOOLS – RIDING INSTRUCTION – CLINICS
1.
2.
3.
You
An Independent Instructor
DESCRIBE TYPE OF SAFETY GEAR REQUIRED
DO YOU PROVIDE RIDING FOR THE HANDICAPPED
Yes
GROSS ANNUAL RECEIPTS
$
No
5.
6.
7.
8.
NUMBER OF HORSES AVAILABLE FOR HANDICAPPED
NON-PROFIT
Yes
No
RATIO OF INSTRUCTORS TO STUDENTS
ARE SIDEWALKERS USED
MAXIMUM NUMBER OF SCHOOL HORSES AVAILABLE
MAXIMUM NUMBER USED AT ANY ONE TIME
ARE STALLIONS USED FOR INSTRUCTION
IF SO, INDICATE THE LEVEL OF THE RIDER AND AGE
VOLUNTEER COVERAGE REQUESTED
Yes
4.
CHECK IF NO EXPOSURE AND INITIAL
If an independent
ARE YOU A CERTIFIED INSTRUCTOR
instructor/trainer is used,
Yes
No
complete Section IV.
IS INSTRUCTION PROVIDED BY
No
GROSS ANNUAL RECEIPTS
$
Yes
No
DO YOU GIVE INSTRUCTION TO STUDENTS ON
THEIR OWN HORSES
Yes
IF SO, ADVISE AVERAGE NUMBER OF LESSONS PER WEEK ANNUAL GROSS RECEIPTS
$
No
DO YOU TEACH
English
Jumping
Saddle Seat
Western
Dressage
Other:
IS THERE ANY PERIOD OF THE YEAR DURING WHICH YOU DO NOT GIVE INSTRUCTIONS – IF SO, GIVE DATES CLOSED
Yes
No
PAGE 3
A4230.DOC-0201
SECTION III. continued
9.
10.
11.
12.
Injuries to horses and
students being transported
are not covered.
DO YOU ATTEND OFF-PREMISES SHOWS WITH YOUR STUDENTS
Yes
No
DO YOU HOLD CLINICS FOR NON-STUDENTS
Yes
$
AVERAGE ATTENDANCE
HOW MANY DAYS
OVERNIGHT CAMP
No
Yes
DO YOU PROVIDE FOOD
No
Yes
GROSS RECEIPTS FOR CAMP
$
No
DESCRIBE ALL ACTIVITIES OFFERED AT CAMPS OTHER THAN RIDING INSTRUCTIONS
SECTION IV. INDEPENDENT INSTRUCTORS / TRAINERS
1.
RECEIPTS EARNED
$
No
DO YOU OPERATE A DAY CAMP
Yes
CHECK IF NO EXPOSURE AND INITIAL
GROSS RECEIPTS
HOW MANY TIMES PER YEAR
DO INDEPENDENT TRAINERS OR INSTRUCTORS OPERATE ON YOUR PREMISES – IF SO, HOW MANY
CHECK IF NO EXPOSURE AND INITIAL
DO THEY CARRY THEIR OWN INSURANCE++
Yes
No
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.
3.
HOW MANY HORSES ARE PROVIDED FOR LESSONS BY
GROSS RECEIPTS
INDEPENDENT INSTRUCTORS
$
GROSS RECEIPTS FOR INSTRUCTION TO STUDENTS
ON THEIR OWN HORSES
HOW MANY OF YOUR BOARDED HORSES ARE BEING TRAINED BY INDEPENDENT TRAINERS
SECTION V. PONY RIDES / SADDLE ANIMALS FOR HIRE / HOURLY OR DAILY RENTALS /
TRAIL RIDES / LEASING / PACK TRIPS
1.
2.
3.
GROSS RECEIPTS FOR RENTALS
GROSS RECEIPTS FOR TRAIL RIDES
RENTAL OR TRAIL RIDES
$
$
2.
3.
4.
5.
6.
7.
8.
9.
DO YOU CONDUCT PACK TRIPS
Yes
No
DO YOU USE SIDEWALKERS
$
Yes
No
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
1.
CHECK IF NO EXPOSURE AND INITIAL
NUMBER OF ANIMALS AVAILABLE FOR
PONY RIDES/PARTIES: NUMBER OF PONIES GROSS RECEIPTS
$
OR TRAINED UNDER YOUR NAME
DO YOU SELL HORSES
Yes
HOW MANY PER YEAR
IF YES
DO YOU SELL FROM YOUR OWN PREMISES
$
No
IS BUYER ALLOWED TO TEST RIDE
Yes
CHECK IF NO EXPOSURE AND INITIAL
GROSS ANNUAL RECEIPTS
WHAT BREEDS
No
In arena
In open field
Yes
No
EXPLAIN ANY OTHER METHOD OF SALES
DO YOU SELL FOOD OR HAVE A SNACK BAR
Yes
No
Liquor liability not
covered.
DO YOU SELL TACK AND/OR CLOTHING – IF YES, USED OR NEW
Yes
No
Used
DO YOU SELL HAY OR FEED
Yes
No
New
GROSS RECEIPTS
$
GROSS RECEIPTS
$
GROSS RECEIPTS
$
DO YOU MIX FEED FOR SALE/CONSUMPTION
Yes
No
DO YOU REPAIR RIDING EQUIPMENT FOR OTHERS
Yes
No
DO YOU PERFORM ANY TYPE OF FARRIER SERVICES
Yes
No
Injury to horse ARE SERVICES ON PREMISE ONLY
not covered.
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.
PAGE 4
A4230.DOC-0201
SECTION VII. RIDES, HORSE SHOWS AND MISCELLANEOUS ACTIVITIES
RIDES
1.
HAY
SLEIGH
CARRIAGE
2.
NUMBER OF
PASSENGERS
4.
5.
6.
7.
8.
NUMBER OF
WAGONS
Independent vendors
are not covered.
Yes
No
NUMBER OF
PARTICIPANTS
ON OR OFF
PREMISES
SHOW DATES
$
$
DOES NUMBER OF SPECTATORS EVER EXCEED 500 PER DAY
No
DO YOU HAVE BLEACHERS OR GRANDSTANDS
Yes
No
CONSTRUCTION
YEAR BUILT
IF YES, WHAT TYPE
DO YOU OWN/USE/LEASE ANY HOUNDS FOR HUNTS HOW MANY HOUNDS
SEATING CAPACITY – NUMBER
No
DO YOU MANAGE ANY HUNTS OR RACING EVENTS
Yes
NUMBER OF
TRIPS
Yes
No
MAXIMUM NUMBER OF TOTAL NUMBER OF
SPECTATORS PER DAY
SHOW DAYS
GROSS RECEIPTS
(ALL SHOWS)
DO YOU SECURE RELEASES FROM ALL ENTRANTS – ATTACH SAMPLE
Yes
NUMBER OF
MOTOR VEH
DO YOU MANAGE ANY SHOWS OPEN TO BOARDERS OR NON-STUDENTS ARE THESE SHOWS RECOGNIZED BY THE AMERICAN HORSE SHOW ASSOC.
SHOWS
Yes
CHECK IF NO EXPOSURE AND INITIAL
NUMBER OF
HORSES
$
SHOWS
ON PREMISES
RODEOS
ON PREMISES
3.
GROSS
RECEIPTS
No
Yes
No
IF RODEOS ON PREMISE, DESCRIBE TYPE OF EVENTS
DO YOU ALLOW NON-BOARDERS TO USE YOUR FACILITIES. IF YES, PLEASE EXPLAIN.
Yes
No
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)
POLICY
POLICY
NUMBER OF
COMPANY
NUMBER
PERIOD
PREMIUM
CLAIMS
1.
2.
3.
LOSSES AND
RESERVES
HAVE YOU HAD ANY LOSSES IN THE PAST FIVE (5) YEARS – IF YES, GIVE APPROXIMATE DATES AND EXPLANATIONS INCLUDING PAYMENTS MADE
Yes
No
HAVE YOU BEEN CANCELLED OR DENIED COVERAGE IN THE LAST THREE (3) YEARS – IF YES, PLEASE EXPLAIN
Yes
No
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
/
/
DATE
X
/
/
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
You may use this page to supplement your application with any additional information.
THANK YOU!
PAGE 6
A4230.DOC-0201
WE OFFER THE FOLLOWING MARKETS AND PRODUCTS:
Insurer
American Bankers Insurance Co. of FL (Various States)
American Reliable Insurance Co.
Atlantic Casualty
Burlington Insurance Co.
Chubb Insurance Co. Personal Lines Only
First Financial Insurance Co. (Oregon)
Founders Insurance Company
General Star Indemnity
Lexington Insurance Co. Personal Lines Only
Mount Vernon Insurance Co.
National Casualty Co.
Rainier Insurance Co. Commercial Lines Only
Red Shield Insurance Co.
Scottsdale Insurance Co.
Sutter Insurance Co. (Oregon, Washington)
Underwriters at Lloyds, London
United States Liability Ins. Co.
A.M. Best
A XI
A-VII
A-VII
A-IX
A++XV
A-IX
A-VII
A++XV
A+XV
A++IX
A+XV
A VI
A VI
A+XV
A-VI
A XV
A++IX
*Unless otherwise noted, the above markets are available in Oregon, Washington, and Idaho.