Equine Liability Waivers, Kentucky

Document Sample
Equine Liability Waivers, Kentucky Powered By Docstoc
					                                 Farm/Ranch/Equestrian Program
Agency:           ________________________________                Policy/Renewal #
Address:          ________________________________                _____________________________
                  ________________________________                Producer:
                                                                  ___________________________________
Phone #: (          )            Fax #: (      )                  Desired Effective Date: / /

Applicant: _______________________________________ _______________________________

Farm Name (DBA): ________________________________________________________________

Mailing Address: ________________________________________ _____________________________________

City: __________________________________ State: ________ Zip: ___________ County: _________________

SS#: ___________________ Phone: ______________________ Contact Person: ________________________


Number of Acres: _____________________ Location Address: __________________________________________

Additional Location(s): __________________________________________________________________________

Does Insured:        ‫ ڤ‬Own             ‫ ڤ‬Lease
Type of Ownership: ‫ ڤ‬Individual        ‫ ڤ‬Corporation         ‫ ڤ‬Partnership          ‫ ڤ‬Trust         ‫ ڤ‬LLC
Names of all partners/officers of Corporation:

Current Insurance Company:                                   Expiration Date:                   Annual Premium:

Have you had any claims and/or reported incidents in the past 3 years?                                 ‫ ڤ‬Yes ‫ ڤ‬No
If yes, explain all claims and/or incidents. Give dates, cause of loss, amounts paid.


Have you had coverage cancelled, non-renewed, or refused in the past three years?                      ‫ ڤ‬Yes ‫ ڤ‬No
If yes, explain:




Name and address of Mortgagee:                                   Name and address of Loss Payee:

________________________________________________                 _____________________________________________




Loan #                                                           Loan #
_______________________________________________                  _____________________________________________

*Note buildings applicable to.                                   *Note buildings/equipment applicable to.



Describe Any Farming Operations Other Than Equine: _______________________________
Gross Annual Receipts: $ _______________________________Contract Labor? oN ‫ ڤ‬seY ‫ڤ‬
How Is Product Sold? ______________________________________________________________

How long has producer known applicant: __________ Date producer last inspected the premise: _______________



                                                                                                                    1
                                              Building Coverage Form
Applicant:
SEPARATE PROPERTY COVERAGE FORM FOR EACH LOCATION WITH STRUCTURES TO BE INSURED
Location: (if different from page 1) Street: ____________________________________________________________
City: _______________________________ State: _____________ Zip: ____________ County: _________________
                                                        Name of responding fire department.                  Feet      Miles from        Other
Deductible: Dwelling & Farm Structures                  Full Time or Volunteer?                              from         Fire           Water
                                                                                                            Hydrant    Department        Source
005,2$ ‫ڤ $500 ڤ $1,000 ڤ‬
Other: $_________________

Location #                        Main Dwelling                               Other Dwellings and Farm Structures
Building Description
Diagram #
Primary Residence?            Yes   ‫ڤ‬No ‫ڤ‬
A. Coverage Amount            $                         $                 $                   $                 $                 $
B. Appurtenant Structures     $                         $                 $                   $                 $                 $
C. Household Contents         $                         $                 $                   $                 $                 $
D. Loss Of Use                $                         $                 $                   $                 $                 $
                              cisaB ‫ڤ‬                   B ‫ڤ‬asic           cisaB ‫ڤ‬             cisaB ‫ڤ‬           cisaB ‫ڤ‬           cisaB ‫ڤ‬
        Covered Causes
                              daorB ‫ڤ‬                   daorB ‫ڤ‬           daorB ‫ڤ‬             daorB ‫ڤ‬           daorB ‫ڤ‬           daorB ‫ڤ‬
            of Loss
                              laicepS ‫ڤ‬                 laicepS ‫ڤ‬         laicepS ‫ڤ‬           laicepS ‫ڤ‬         laicepS ‫ڤ‬         laicepS ‫ڤ‬
                                                                          RC ‫ڤ‬    ACV         RC ‫ڤ‬    ACV       RC ‫ڤ‬    ACV       RC ‫ڤ‬    ACV
Loss Settlement               RC     ‫ڤ‬ACV ‫ڤ‬             RC ‫ڤ‬    ACV ‫ڤ‬
                                                                          ‫ڤ‬                   ‫ڤ‬                 ‫ڤ‬                 ‫ڤ‬
Earthquake Coverage           Yes ‫ڤ‬No ‫ڤ‬                 Yes  ‫ڤ‬No ‫ڤ‬        Yes  ‫ڤ‬No ‫ڤ‬          Yes ‫ڤ‬No ‫ڤ‬         Yes ‫ڤ‬No ‫ڤ‬         Yes ‫ڤ‬No ‫ڤ‬
                              ‫ڤ‬Owner                     ‫ڤ‬Owner            ‫ڤ‬Owner             ‫ڤ‬Owner            ‫ڤ‬Owner            ‫ڤ‬Owner
Occupancy                     ‫ڤ‬Tenant                    ‫ڤ‬Tenant           ‫ڤ‬Tenant            ‫ڤ‬Tenant           ‫ڤ‬Tenant           ‫ڤ‬Tenant
                              ‫ڤ‬Caretaker/Employee        ‫ڤ‬Caretaker        ‫ڤ‬Caretaker         ‫ڤ‬Caretaker        ‫ڤ‬Caretaker        ‫ڤ‬Caretaker
# of Families
Year Built
Type of Construction
Roof:             Type
                  Age
                  Source
Heating: Type of Furnace
                  Age
Cooling                       Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Smoke Alarm                   Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Type of System
Burglar Alarm                 Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Central Station Fire Alarm    Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Lightning Rods                Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Fire Extinguishers            Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Sprinkler System              Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
Hay Storage                                             Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬        Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬      Yes    ‫ڤ‬No ‫ڤ‬
                              Wiring ___________ yr.    Wiring ____ yr.   Wiring ____ yr.     Wiring ____ yr.   Wiring ____ yr.   Wiring ____ yr.
Renovation Update:
                              Heating __________ yr.    Heat______ yr.    Heat______ yr.      Heat______ yr.    Heat______ yr.    Heat______ yr.
Year of Update for
                              Plumbing _________ yr.    Plumb_____yr.     Plumb_____yr.       Plumb_____yr.     Plumb_____yr.     Plumb_____yr.
Buildings over 25 yrs.
                              Roof _____________yr.     Roof ______yr.    Roof ______yr.      Roof ______yr.    Roof ______yr.    Roof ______yr.
Wood Stove (see pg 10)        Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ ڤ‬Yes         ‫ڤ‬No ‫ ڤ‬Yes ‫ڤ‬No ‫ڤ‬                Yes  ‫ڤ‬No ‫ ڤ‬Yes ‫ڤ‬No ‫ڤ‬
Mobile Buildings (see pg 4)   Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ ڤ‬Yes         ‫ڤ‬No ‫ ڤ‬Yes ‫ڤ‬No ‫ڤ‬                Yes  ‫ڤ‬No ‫ ڤ‬Yes ‫ڤ‬No ‫ڤ‬
Exposed Urethane Styrene      Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No ‫ ڤ‬Yes         ‫ڤ‬No ‫ ڤ‬Yes ‫ڤ‬No ‫ڤ‬                Yes ‫ڤ‬No ‫ڤ‬  Yes ‫ڤ‬No ‫ڤ‬
Asbestos:                     Yes   ‫ڤ‬No ‫ڤ‬               Yes    ‫ڤ‬No  ‫ڤ‬Yes         ‫ڤ‬No   ‫ڤ‬Yes ‫ڤ‬No                 ‫ڤ‬Yes ‫ڤ‬No ‫ڤ‬Yes ‫ڤ‬No ‫ڤ‬
Remarks:

Type of Construction: Frame, Masonry, Steel Frame, Pole, Mobile Home/Mobile Building. Type of Roof: Asphalt/Metal/Tile/Cedar
Loss Settlement: RC = Replacement Cost / ACV = Actual Cash Value / SIP = Self-Insurance Provision.


                                                                                                                                                  2
                                                                                Property Diagram
Applicant:                                                                                                                                                      Location #

                                                                            Property Diagram for Each Location

                                              Show all buildings on premises (whether or not insured).
                                    Show distance in feet between buildings as well as square footage of buildings.
                                                 Label all buildings and attach dated photographs.
                                                              Label “NC” if not covered.

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Show nearest Road, Highway or Interstate.                                                                                       Show Fire Hydrant if Applicable.
Show any Lakes, Rivers, or Ponds.                                                                                               Show Fuel Tank Locations.




                                                                                                                                                                                                                    3
                                   Scheduled Farm & Personal Property
Applicant:
                                                        Scheduled Property

Deductible: 005$ ‫ڤ‬                  Please list all Tractors, Tractor Implements, Other Farm
                                                                                                             Covered Cause of Loss:
               000,1$ ‫ڤ‬             Machinery, Hay, Irrigation Equipment, Tack & Grooming
                                                                                                                    ‫ڤ‬Basic
              005,2$ ‫ڤ‬              Equipment, Small Tools & Supplies, Jewelry, Watercraft,
                                                                                                                     ‫ڤ‬Broad
                 000,5$ ‫ڤ‬           Guns, Furs, Fine Arts, Cameras, Coins, Sports Equipment,
                                                                                                                     ‫ڤ‬Special
            :rehtO ‫ڤ‬                Silverware, Computers and all other similar items.

                Type                      Description of item, model #, year, and serial number.                   Insured Amount




                                                        TOTAL FARM & PERSONAL PROPERTY:                     $

                                                 Mobile Home Tie Down Report
                                                                       Please show a diagram of the mobile home including tie downs.
Make of mobile home: _________________________________

Model: ______________________________________________

Year built: ___________________________________________

Year Installed: ________________________________________



   Length of           Frame Ties and
                                              Over Home Ties
    Home               Anchors per Side

   Up to 40’                  4                     2

   41’ to 60’                 6                     3

   61’ to 82’                 8                     4


Does the Mobile Home meet the minimum tie down
requirements?                                  ‫ ڤ‬Yes ‫ ڤ‬No
Is the mobile home skirted?                    ‫ ڤ‬Yes ‫ ڤ‬No




                                                                                                                                       4
                                                        Liability Section
                                                Limits and Coverage Options

Each Occurrence Limit                                                                           ‫000,005$ڤ‬              ‫000,000,1$ڤ‬
Fire Damage Limit (Any one Fire)                                                                     $50,000                  $50,000
Medical Payments (Any one Person)                                                                     $5,000                   $5,000
                                             oN ‫ ڤ‬seY ‫ڤ‬
Products and Completed Operations                                    PLEASE COMPLETE THE
                                             ‫ ڤ‬seY ‫ ڤ‬No
Excess Coverage                                                      UMBRELLA ACORD FORM FOR
                                             $1m ‫2$ ڤ‬m ‫3$ ڤ‬m ‫ڤ‬
Excess Limits:                                                       EXCESS COVERAGE
                                             $4m ‫ ڤ‬Other ‫ڤ‬
1.    Does applicant hire any part time or full time             24. Does applicant handle any product, such as       Y‫ڤ‬N ‫ڤ‬
      workers? If yes, how many PT? ___FT? ___          Y‫ ڤ‬N‫ڤ‬        seed, fertilizer, or sprays for resale?
2.    Does applicant carry Worker                                25. Any contract service operations performed
      Compensation/Employers Liability?                 Y‫ ڤ‬N‫ڤ‬        for others such as tilling, excavating, or       Y‫ ڤ‬N‫ڤ‬
3.    Does applicant have any leased workers?           Y‫ ڤ‬N‫ڤ‬        ditching?
4.    Does applicant trade or exchange lesson,                   26. Are farm premises open to the public for
      boarding, or other services for work                           roadside stands, u-pick, rent-a-garden,
      performed on the applicants behalf?               Y‫ ڤ‬N‫ڤ‬        auction, sales, food or beverage service, or     Y‫ ڤ‬N‫ڤ‬
5.    Does applicant own any rental property?           Y‫ ڤ‬N‫ڤ‬        Christmas tree sales?
6.    Is any land held for real estate development               27. Is there any unusual hazard such as (but not
      or speculation?                                   Y‫ ڤ‬N‫ڤ‬        limited to) open dump pits, silage pits, or      Y‫ ڤ‬N‫ڤ‬
7.    Does applicant maintain any vacation or                        sump holes?
      seasonal premises?                                Y‫ ڤ‬N‫ڤ‬    28. Is there an airstrip on premises? If yes,
8.    Are any portions of the farm rented or leased                  please describe type of use, who uses, and       Y‫ ڤ‬N‫ڤ‬
      or used by any other individual, corporation,                  frequency.__________________________
      or other interest for any activities other than            29. Is there a trampoline on premises?               Y‫ ڤ‬N‫ڤ‬
      farming?                                          Y‫ ڤ‬N‫ڤ‬    30. Any business enterprises or professional
9.    Does applicant grow or store tobacco?             Y‫ ڤ‬N‫ڤ‬        offices on any of the described premises?        Y‫ ڤ‬N‫ڤ‬
10.   Is farming/equine the major source of                          Description________________________
      applicant’s income? If no, please explain.        Y‫ ڤ‬N‫ڤ‬    31. Does applicant lease any part of the land,
11.   Has the applicant ever filed for bankruptcy?      Y‫ ڤ‬N‫ڤ‬        buildings, stables, and stall space,
12.   Any paying guests on premises (hunting,                        operations to others?                            Y‫ ڤ‬N‫ڤ‬
      fishing, dude ranch, bed & breakfast, resort)?    Y‫ ڤ‬N‫ڤ‬    32. Are all livestock areas completely fenced?       Y‫ ڤ‬N‫ڤ‬
13.   Is there a swimming pool on premises? Is it                33. Is there a telephone on premises?                Y‫ ڤ‬N‫ڤ‬
      fenced? Diving board? Depth? __________           Y‫ ڤ‬N‫ڤ‬    34. Does applicant own/maintain any other
14.   Any other bodies of water on premises? If         Y‫ ڤ‬N‫ڤ‬        animals such as ostriches, emus, chickens,       Y‫ ڤ‬N‫ڤ‬
      so, please describe. ___________________                       etc? If yes, type & number?_____________
15.   Any commercial food processing?                   Y‫ ڤ‬N‫ڤ‬    35. Hunting on premises? If yes, by: ‫ ڤ‬Owners?       Y‫ ڤ‬N‫ڤ‬
16.   Any custom farming? If so, gross annual                        ?eef a egrahc tnacilppa seoD ?srehtO ‫ڤ‬           Y‫ ڤ‬N‫ڤ‬
      receipts? ____________________________            Y‫ ڤ‬N‫ڤ‬    36. Does applicant own/maintain dogs? If yes,        Y‫ ڤ‬N‫ڤ‬
17.   Any independent contractors hired to                           how many and what breed(s)? If mixed,
      perform any farming operations? If yes,           Y‫ ڤ‬N‫ڤ‬        please indicate breeds_________________
      please describe.______________________                     37. Has any dog which applicant owns or on
18.   Does the applicant own any recreational                        applicants premises bitten or caused injury      Y‫ ڤ‬N‫ڤ‬
      vehicles? If so, what type and how                Y‫ ڤ‬N‫ڤ‬        to anyone? If yes,
      many?_________________ Farm use only?             Y‫ ڤ‬N‫ڤ‬        when?________________________
19.   Does the applicant have any camping areas
      or places where trailers can be parked?           Y‫ ڤ‬N‫ڤ‬    For all food producers, please go this website for
20.   Any non-farming activities such as                         important compliance information:
      excavating, snow removal, or other non-
      farming pursuits?                                 Y‫ ڤ‬N‫ڤ‬       www.cfsan.fda.gov/%7edms/secguid.html
21.   Does applicant allow the premises to be
      used for any activities such as snowmobile
      races, rodeos, roping contests, or other                   Remarks:
      similar recreational use?                         Y‫ ڤ‬N‫ڤ‬    _______________________________________
22.   Does applicant build, repair, or design                    _______________________________________
      machinery, equipment, or systems for                       _______________________________________
      anyone for a fee?                                 Y‫ ڤ‬N‫ڤ‬    _______________________________________
23.   Does applicant mix, process, slaughter,                    _______________________________________
      butcher, or otherwise prepare for “end                     _______________________________________
      consumer” his or any other grower’s               Y‫ ڤ‬N‫ڤ‬
      product? If yes, please describe and provide
      receipts_____________________________



                                                                                                                                   5
                                       Equine Commercial General Liability
NON RO DENWO ON ERA EREHT FI EREH KCEHC ESAELP ‫-ڤ‬OWNED HORSES KEPT ON ANY DESCRIBED PREMISES. IF
THERE ARE NO HORSES YOU CAN DISREGARD PAGES 6-9 OF THE APPLICATION.
                                                     Definitions and Instructions
Commercial General Liability: Coverage for Commercial Equine Activities that are both declared and approved on the application.

Personal Horse Owner’s Coverage: Provides coverage for personal, non-commercially owned pleasure horses both on and off premises.

Excess Limits: Increases the per occurrence and aggregate limit. Primary limits of 1 million per occurrence and 2 million aggregate are
required.

Additional Insured’s: List Land Owners and/or Owners of facilities leased, etc. Spouses are covered automatically, but if children are of legal
age and are part of your commercial operations, they need to be listed as Additional Insured’s. Independent Instructors/Trainers and Employees are
not qualified. (An Employee is an insured while working within their job description.)

Independent Trainers/Instructors: List all Riding Instructors and Trainers who utilize your facility. On Premise Coverage will be provided
for those Independent Riding Instructors and Trainers listed. If any Instructors and/or Trainers require Off Premises coverage, they must complete
their own application. We will provide a quotation to cover your Riding Instructor’s activities, which will avoid duplication of coverage and cost. If
your Independent Instructor or Trainer has coverage elsewhere, please send proof of coverage listing you and your business as an additional
insured. (An Employee is an insured while working within their job description.)

Care, Custody & Control: CCC coverage is to protect you in case of a lawsuit claiming negligence by you or an employee resulting in injury
or death of a horse that is in your Care, Custody and Control. There is NO coverage provided under the Commercial General Liability for other
people’s horses in your care.

Remember: If you have activities that are not described within the application, they must be listed with explanations, volume of activity,
and revenues for coverage to be considered.

List Additional Insured’s with relationship descriptions. (Independent Instructors/Trainers and Employees Do Not Qualify.)

Name:_____________________________
Address:_______________________________________________________________________________________________
Relationship:________________________
Name:____________________________Address:________________________________________________________________
                        ____________________________Relationship:_______________________
Name:_________________________
Address:_______________________
______________________________
______________________________
Relationship:____________________




                                                     Summary of Equestrian Activities
Give a brief description of your operation:
______________________________________________________________________________________________________________________
There is NO COVERAGE provided for Commercial Trail Ride Operations!
How often and for what reasons are owned/leased horses taken off premise:

______________________________________________________________________________________________________________________


Total Professional Years in this type of operation: ____________ Briefly list Officiating, Judging and/or Instructors Licenses and/or Competition
experience:

If you are not the primary Manager, Manager’s Name:________________________________ Years Experience:______________


24-hour supervision of the facility?                                                                                         Helmets are Required:




                                                                                                                                                         6
Emergency numbers posted?                     Yes ‫ڤ‬                       No ‫ڤ‬    eht fo lla enoyreve yB ‫ڤ‬
Safety and Barn Rules Posted?                 Yes ‫ڤ‬                       No ‫ڤ‬   time
Current liability waivers utilized?           Yes ‫( ڤ‬Enclose copies)      No ‫ڤ‬    eht fo lla rednu dna 81 ‫ڤ‬
Boarding/Breeding/Training agreements?        Yes ‫( ڤ‬Enclose copies)      No ‫ڤ‬   time
Smoking allowed in barns?                     Yes ‫( ڤ‬Enclose copies)      No ‫ڤ‬   gnipmuj elihw enoyrevE ‫ڤ‬
Shoes with heels required?                    Yes ‫ڤ‬                       No ‫ڤ‬    elihw 81 rednu ylnO ‫ڤ‬
State Equine Liability Signs posted?          Yes ‫ڤ‬                       No ‫ڤ‬   jumping
                                              Yes ‫ڤ‬                       No ‫ڤ‬   deriuqer reveN ‫ڤ‬
Describe precautions to keep horses from having access to public roads:




                                                                                                              7
                              Equine Commercial General Liability
Please indicate the number of horses owned, leased or used by you for the activities listed below in column #1.
Indicate the average number of non-owned horses in column #2. DO NOT COUNT each horse more than once.


                                                        Column #1
                                                        Column #2

                                                      ACTIVITY
                                                   OWNED HORSES
                                                 NON-OWNED HORSES

                                           SHOW/PLEASURE/PERSONAL USE



                                                      TRAINING (SHOW)



                                                 RIDING INSTRUCTION



                                                         BREEDING



                                           BOARDED (STALL AND PASTURE)



                                                 RACE/RACE TRAINING



                                                YEARLINGS/WEANLINGS



                                          RENTALS/TRAIL RIDES/PONY RIDES



                                          ANY OTHER USE, PLEASE EXPLAIN




Type of Instruction given:_____________________________________________________________________________________________

Please do not include independent trainers/instructors exposure below. Please see attached supplement on page 9.
Average Weekly Lessons given on CLIENT’S horse(s):      ____ How many students do you have?________
Annual Number of Lessons given on CLIENT’S horse(s):    ____   Gross annual receipts (Client’s horse(s)):________

Average Weekly Lessons given on APPLICANT’S horse(s): ____     Gross annual receipts (Applicant’s horse(s)) ________

Maximum number of school horses available: ________            Maximum number used at any one time: ________

On Premises Riding Clinics                  oN ‫ ڤ‬seY ‫ڤ‬         Total Clinic Days: ________ # Participants per day: ________
Off Premises Riding Clinics                 oN ‫ ڤ‬seY ‫ڤ‬         Total Clinic Days: ________ # Participants per day: ________




                                                                                                                              8
                                                                               # Sanctioned Shows:_______ # Non-Sanctioned Shows_____

                                                                               PLEASE NOTE: COVERAGE IS NOT PROVIDED FOR
                                                                               “BODILY INJURY” TO ANY PERSON WHILE PRACTICING
     Hosted Shows/Events                                 oN ‫ ڤ‬seY ‫ڤ‬
                                                                               FOR OR PARTICIPATING IN ANY SPORTS OR ATHELETIC
                                                                               CONTEST OR EXHIBITION. A copy of the entire wording can
                                                                               be provided upon request.

     Number of Competitors at any one Event: ________                          List all show dates:
     Number of Spectators at any one Event: ________                           __________________________________________________
     Grand Stands                                 oN ‫ ڤ‬seY ‫ڤ‬
     Maximum Seating ________Construction Type______________                   __________________________________________________

     Concession stand on premises?                       oN ‫ ڤ‬seY ‫ڤ‬            __________________________________________________
     What type of sales? ___________________             oN ‫ ڤ‬seY ‫ڤ‬
     Any liquor sold?                                    oN ‫ ڤ‬seY ‫ڤ‬
                                                                               All dates must be declared before actual event date.
     Tack Store/Retail Sales                              ‫ڤ‬Yes     ‫ڤ‬No
                                                                               (Tack repair not eligible.) Total annual Gross tack sales:
     Any used tack sales?                                 ‫ڤ‬Yes     ‫ڤ‬No
                                                                               $______________
     Pony & Horse Drawn Vehicle Rides                     ‫ڤ‬Yes     ‫ڤ‬No
     Horse Sales                                         oN ‫ ڤ‬seY ‫ڤ‬            Total Owned & Non-owned horses sold annually________
     Independent Trainers/Instructors                    oN ‫ ڤ‬seY ‫ڤ‬            (If yes, please complete the Independent Form on page 9.)
                                                                               Do you provide any farrier services?           oN ‫ ڤ‬seY ‫ڤ‬
     Do you provide riding for the handicapped?           oN ‫ ڤ‬seY ‫ڤ‬
                                                                               If yes, on premises only?                      oN ‫ ڤ‬seY ‫ڤ‬
     Do you provide horse rentals or offer trail
                                                           seY ‫ ڤ‬oN ‫ڤ‬          Farrier Receipts:_______________
     rides?
     Number of carts/buggies/wagons                                            Riding Facilities:
                                                         ___________
     owned/used in public events                                               Arena: sliarT ‫ ڤ‬sdleiF nepO ‫ڤ‬            roodtuO ‫ڤ‬      roodnI ‫ڤ‬


                                                        Care Custody & Control
     Is Care, Custody and Control Coverage desired? (If yes, indicate limit below.) oN ‫ ڤ‬seY ‫ڤ‬
     If you marked no, please sign here to verify that CCC coverage has been explained to you and you choose to decline the coverage
      at this time.

     Signature ________________________________________________________________________________

     Check one                 Limit Per Horse                      Limit Per Occurrence                        Aggregate
          ‫ڤ‬                         $500                                   $5,000                                 $5,000
          ‫ڤ‬                        $1,000                                 $10,000                                 $10,000

          ‫ڤ‬                         $2,500                                $25,000                                 $25,000
          ‫ڤ‬                        $5,000                                 $25,000                                 $25,000
          ‫ڤ‬                        $10,000                                $50,000                                 $50,000
          ‫ڤ‬                        $10,000                               $100,000                                $100,000
          ‫ڤ‬                        $25,000                               $250,000                                $250,000
          ‫ڤ‬                        $50,000                               $250,000                                $250,000
          ‫ڤ‬                       $100,000                               $300,000                                $300,000
          ‫ڤ‬                       $200,000                               $500,000                                $500,000
          ‫ڤ‬             Other Limits May Be Available


1.    Minimum number of non-owned horses in your care ______                 8.     Is wire utilized in the construction of pasture fences,
2.    Maximum number of non-owned horses in your care ______                        paddocks or any area that non-owned horses will have
3.    Minimum value of non-owned horses in your care      ______                    access?                                                 Y‫ ڤ‬N‫ڤ‬
4.    Maximum values of non-owned horses in your care ______                        Type of fencing?___________________________________
5.    Average number of non-owned horses in your care ______                 9.     Are shelters provided in runs or pastures? If yes, please
6.    Average value of non-owned horses in your care      ______                    describe.__________________________________Y ‫ ڤ‬N ‫ڤ‬
7.    What type of fencing is used in runs, pastures, and                    10.    Where are non-owned horses kept at night (stable, pasture,
      paddocks?________________________________________                             etc.)?____________________________________________

                                                                                                                                                  9
11.   Is smoking allowed within structures?                  Y‫ ڤ‬N‫ڤ‬        Do at least two people go on each trip?               Y‫ ڤ‬N
12.   Are stallions housed, pastured and exercised in                      sdraobroolf (s)nav ro (s)reliart era netfo woH ‫ڤ‬
      separate pastures, paddocks and runs,                               checked?_____
      away from mares?                                       Y‫ ڤ‬N‫ڤ‬    24. Are there therapeutic pools for horses?               Y‫ ڤ‬N‫ڤ‬
13.   Do all electrical lights have explosion proof covers? Y ‫ ڤ‬N ‫ڤ‬       If yes, were they installed by the manufacturer?      Y‫ ڤ‬N
14.   Are electrical outlets inaccessible to horses?         Y‫ ڤ‬N‫ڤ‬        ‫ڤ‬
15.   Does applicant mix own concentrate feed rations                 25. Do employees (if any) have written instructions on their
       on the premises?                                       Y‫ ڤ‬N‫ڤ‬       responsibility in case of a stable fire?              Y‫ ڤ‬N‫ڤ‬
16.   Is feed stored in the stabling area?                    Y‫ ڤ‬N        If yes, please provide a copy of those instructions.
      ‫ڤ‬                                                               26. Name/Address of regular Veterinarian:_________________
17.   Is the feed room secured with horse proof latches? Y ‫ ڤ‬N ‫ڤ‬          ________________________________________________
18.   What is the construction and type of stalls?______________      27. How often is he/she on premises?_____________________
19.   Size of stalls (sq. ft. & height)?________________________      28. Describe any losses or potential claims in the past three
20.   Do you require the owner(s) to provide health statements            years. Include any deaths of any animal(s) in your custody,
      prior to accepting the non-owned horses?               Y‫ ڤ‬N‫ڤ‬        even if a claim was not presented______________________
21.   Explain emergency procedures if horse is ill and the owner         __________________________________________________
      cannot be contacted:______________________________                 __________________________________________________
22.   Are all non-owned horses required to have permanent
      methods of identification, i.e. tags, brands, tattoos,
      registration records? If yes, explain.                 Y‫ ڤ‬N‫ڤ‬       Remarks:__________________________________________
      ________________________________________________                   __________________________________________________
23.   Are non-owned horses transported for others?           Y‫ ڤ‬N‫ڤ‬       __________________________________________________
      If yes:                                                            __________________________________________________
      Maximum number of trips per year______ Maximum number
      of animals per trip_______ Radius of operation?__________
      ________________________________________________
      ________________________________________________




                                                                                                                                   2
                 Independent Trainers and/or Instructors Supplemental Form
On Premise coverage ONLY will be provided for Independents. If any Independent requires OFF Premises
coverage, they must complete their own insurance application for Commercial General Liability. If you have
Independent Instructors or Trainers using your facility and they DO NOT have their own insurance, our
quotation will include the charge for their training and/or instruction exposures. If they DO carry their own
insurance, you will need to be listed as Additional Insured on their policy and provide us with a copy of that
policy upon acceptance of this liability quotation. Remember, employees are not considered Independent
Trainers/Instructors. Do not list them on this form. No exceptions!!

Independent Riding Instructors (Must be 18 years or older.) ‫ڤ‬Yes             ‫ڤ‬No
How many Independent riding instructors use your facilities?____________

Do independents provide any lesson horses? oN ‫ ڤ‬seY ‫ڤ‬How many used at one time?_____ # of shows/clinics?_______# of Participants_____

                                                                                                          Gross        Do they have
                                                              Years
                   Name                          Age                         Type of Instruction Given    annual         their own
                                                            Experience
                                                                                                         receipts       insurance?

1.

2.

3.


4.

5.

6.

7.


Independent Trainers (Must be 18 years or older.) ‫ڤ‬Yes            ‫ڤ‬No
How many Independent trainers utilize your facilities? _____________

                                                                                                            # of
                                                                                                                       Do they have
                                                                                                          Horses
                   Name                          Age      Years Experience         Type of Training                      their own
                                                                                                          Trained
                                                                                                                        insurance?
                                                                                                         per month

1.

2.

3.

4.

5.

6.

7.




                                                                                                                                        9
                                                                                      Applicant’s Name
WOOD/COAL BURNING
STOVE
SUPPLEMENTAL INSPECTION FORM

                                                           htraeH nepO ‫ٱ‬                 ‫ٱ‬Pot Belly, Box or Franklin                        ‫ٱ‬Airtight
                                           Type                                                                                            (Tight-fitting, draft-limiting doors and
                                                              (No doors)                   (Loose fitting doors)
                                                                                                                                        seams)
                                           Construction    ‫ٱ‬Sheet Metal                ‫ٱ‬Cast               ‫ٱ‬Brick Lined           Any Cracks or Broken Parts? ‫ ٱ‬Yes ‫ ٱ‬No
                                                                                      Iron
                                           Fuel            oW ‫ٱ‬od                 laoC ‫ٱ‬                  ______________________________________ :)yficeps( rehtO ‫ٱ‬
             Stove/Furnace Unit




                                                           ecruoS taeH yramirP ‫ٱ‬                         gnitaeH latnemelppuS ‫ٱ‬
                                           Principal Use                                                                                                gnikooC ‫ٱ‬
                                                              (More than 50 days/yr.)                       (Less than 50 days/yr.)

                                           Installed By    renwO ‫ٱ‬                       rotcartnoC ‫ٱ‬                 atsnI fo raeY/htnoM ‫ٱ‬llation _________/___________

                                           Inspected By    rotcepsnI gnidliuB ‫ٱ‬             tnemtrapeD eriF ‫ٱ‬               ___________________________ :)yficeps( rehtO ‫ٱ‬

                                           Installation    Stove placed at least 36” from                Non-combustible pad or surface                 Stove legs allow at least 4” air
                                                           combustible well or furnishings,              below stove, extends at least 18”              space below stove.
                                                           or 18” from non-combustible                   beyond loading door and 12”
                                                           shield with 1” air space to                   beyond side and rear.
                                                           combustible wall.

                                                                  seY ‫ ٱ‬oN ‫ٱ‬                             oN ‫ٱ‬       seY ‫ٱ‬                               oN ‫ٱ‬         seY ‫ٱ‬
                                           Type            yrnosaM ‫ٱ‬                               yenmihC lateM detsiL .L.U ‫ٱ‬
                                                           When last cleaned
                                                                                                         Last inspected                                 Are ashes disposed of in a fireproof
                                           Cleaned/        ________/________
                                                                                                         _________/_________
                                                                                                                                                                             ‫ٱ‬Yes ‫ٱ‬No
Chimney/Chimney Connector




                                           Inspected                              (Mo.                                                                  container?
                                                                                                                        (Mo.         Yr.)
                                                           Yr.)

                                           Installation    Passes through non-combustible                Connector to chimney under 10’ in              Galvanized steel pipe:
                                                           thimble collar or opening which is at         length:
                                                           least 12” larger in diameter than
                                                           stove pipe:
                                                           oN ‫ ٱ‬seY ‫ٱ‬                                    oN ‫ ٱ‬seY ‫ٱ‬                                     oN ‫ ٱ‬seY ‫ٱ‬

                                                           More than two bonds:                          Horizontal portion rises at least ¼”           Pipe sections overlap to contain
                            (Stove Pipe)




                                                                                                         per linear ft. of pipe length so               creosote flow back:
                                                                                                         chimney connection point is higher
                                                                                                         than stove end:
                                                           oN ‫ ٱ‬seY ‫ٱ‬                                    oN ‫ ٱ‬seY ‫ٱ‬                                     oN ‫ ٱ‬seY ‫ٱ‬




                                                                                                                                                                                               10
                                                     GENERAL FRAUD STATEMENT
     (Not applicable in California, Colorado, Florida, Kentucky, Maine New Mexico, New Jersey, New York, Ohio, Pennsylvania, Rhode Island)

Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal and civil penalties .
APPLICABLE IN THE STATE OF CALIFORNIA
For your protection, California law requires the following to appear on this form:
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
APPLICABLE IN THE STATE OF 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.
APPLICABLE IN THE STATE OF MAINE
“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 a denial of insurance benefits”.
APPLICABLE IN THE STATE OF NEW MEXICO
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 .
PENNSYLVANIA FRAUD STATEMENT
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 subjects the person to criminal and civil penalties .
APPLICABLE TO THE STATE OF KENTUCKY
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.
APPLICABLE IN NEW YORK STATE
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 ACT, WHICH
IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE
OF THE CLAIM FOR EACH SUCH VIOLATION.
APPLICABLE IN THE STATE OF OHIO                             FRAUD WARNING
ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT THEY ARE FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
This notice is given as required by the laws of the State of Ohio.
APPLICABLE IN THE STATE OF COLORADO
“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 claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado division of insurance within the department of regulatory services”.
APPLICABLE IN THE STATE OF FLORIDA
Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal penalties.
APPLICABLE IN THE STATE OF NEW JERSEY
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 and subjects the person to criminal and civil penalties.
APPLICABLE IN THE STATE OF RHODE ISLAND
DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON?
YES________ NO________
In Rhode Island, any applicant for property insurance must answer this question. Failure to disclose the existence of an arson conviction is a
misdemeanor punishable by a sentence of up to one year of imprisonment.


I/We understand and agree that any misstatement of warranty or fact on this application shall be considered a violation of
coverage afforded under any policy issued on the basis of this application. I/We understand and agree that this
application shall form a part of any policy issued and that the Company requires that I/We obtain additional insured
certificates of insurance from Independent contractors for coverage to remain in effect. I/We understand any policy issued
will not provide Worker’s Compensation.

Applicant’s Signature: _______________________________ Print: _________________________ Date: __________

Agent’s Signature: __________________________________ Print: _________________________ Date: __________
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DOCUMENT INFO
Description: Equine Liability Waivers, Kentucky document sample