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Location if                        different from above address

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Please Select One ----> Email Phone FAX Postal Contact me by:                                               

Please Select One ----> Yes No Do you currently                                               have a policy?

Policy Re-Newal                                                Date?

Please Select One ----> $300,000 / $600,000 annual $500,000 / $600,000 annual $1,000,000 / $2,000,000 annual Please quote                                               Liability Limit

Please Select One ----> Yes No Has there been      any claims or incidents in the past three                                             years?

Please Select One ----> Yes No Has coverage                been denied and/or cancelled in the                past three Years?                            

Please Select One ----> Yes No Are you leasing                property for your horse operation?

Please Select One ----> Individual Partnership Corporation Association Ownership Type

Total number of owned/leased horses including those owned in partnership:

How many of your owned/leased horses are taken off premises? (horse shows, etc.) ?

Number of stalls                                                on premises

How many years have you been in this type of operation ?

Please Select One ----> Yes No Is there 24 hour                           supervision at your facility ?

Please Select One ----> Yes No Are emergency                                            numbers posted?

Please Select One ----> Yes No Do you have Safety & Barn Rules posted/written out ? (a copy will be requested)

Please Select One ----> Yes No Are State Equine                                      liability signs posted ?

Please Select One ----> Yes No Is Smoking                                           allowed in barns?

Please Select One ----> Yes No Are shoes with                                          heels required ?

Please Select One ----> Yes No Are helmets                                                 required ?

Please Select One ----> By Everone all the time 18 & under all time while jumping & speed work Only 18 & under while jumping Optional When Are helmets                                                 required ?

Describe precautions taken to keep horse(s) from having access to public roads: i.e. fencing, gates, distance from public roads:

Declare all equine activities by marking “yes”. Any events or activities not disclosed or described are NOT COVERED.

Please Select One ----> Yes No Breeding?

Total number of stallions standing at stud on your premises

Total number of stallions which you own or have partial ownership standing at stud off premises

Average stud fee                                               charged

Total number of              mares covered annually on premises

Total number of             mares which you own, covered            annually off premises

Gross annual                                      income from breeding

Please Select One ----> Yes No Do You Board?

Number of horses                                               on Full Board

Amount of Full                                               Board Fee

Number of horses                                               on pasture                                               board

Amount of                                               pasture   board

Please Select One ----> Yes No Do You sell                                               horses?

Number of horses                                                sold annually

Gross annual                                  income from horse sales

Please Select One ----> Yes No Do you train                                                horses?

Average number of horses in training monthly?

Training Fee

Please Select One ----> Yes No Do You have an independent trainer? (not an employee, must be over 18 yrs old)

Please Select One ----> Yes No Do You provide                                         riding instructions ?

Type of instruction

Please Select One ----> Yes No Anyone under 21                               giving riding instructions ?

How Many                           Lessons are given annually ?

Average cost per                                             Lesson ?

How many School Horses are used for riding instructions ?

Maximum # of school horses used at one time

Ratio of instructors to students

Please Select One ----> Yes No   Do you attend off-premises shows with your students

 If Yes, number of off-premises shows attended annually

Gross receipts from attending off-premises shows

Average number of weekly lessons given on School horses?

Average number of weekly lessons given on Client's own horses?

Please Select One ----> Yes No Are there any Day Camp Activities? (If yes, a supplemental application required)

Please Select One ----> Yes No Do you hold on Premises Riding Clinics?

Total clinic days?

Clinic dates?

Number of participants per day:

Please Select One ----> Yes No Do you hold off Premises Riding Clinics?

Total off Premises clinic days?

off Premises Clinic dates?

Number of participants per day:

Please Select One ----> Yes No Do you host shows or other equine events?

Description of equine event activities

Event dates?

Note: If dates have not been set, notice is required for each show/event day for coverage to apply.

Average number of competitors per show/event day

Average number of spectators per show/event day

Maximum number of competitors per show/event day

Maximum number of spectators per show/event day

If you host shows, please answer the following.

Please Select One ----> Yes No Is the show/event sanctioned?

If sanctioned show, provide Sanctioning Organization

Please Select One ----> Yes No Do you sell tack?

Please Select One ----> Yes No Do you offer pony and horse drawn vehicle rides? (Insurance is NOT available for programs designed for the general public)

Please Select One ----> Yes No Do you offer trail rides to the general public? (Insurance is NOT available for programs designed for the general public)

Please Select One ----> Yes No Do you offer horse rental to the public? (Insurance is NOT available for programs designed for the general public)

Please Select One ----> Yes No Is hunting allowed on your premises?

If yes, by whom?

Please Select One ----> Yes No Do you charge a fee?

Please Select One ----> Yes No Do you operate a bed and breakfast? (Insurance is NOT available for programs designed for the general public )

Please Select One ----> Yes No Is there a swimming pool on the premises?

Please Select One ----> Yes No If yes, is there a security fence around the pool?

Please Select One ----> Yes No Do you own dogs?

If yes, please provide the number of dogs, breed and purpose (i.e., pets, barn dogs, etc.)

Please Select One ----> Yes No Are other dogs permitted at your facility?

Please Select One ----> Yes No Has any dog you own or on your premises bitten or caused injury to anyone ?

Please Select One ----> Yes No Are there other animals on premises ?

If yes, please describe (i.e., 3 barn catss, 2 goats etc.)

Please Select One ----> Yes No Is there alcohol sold on your premises?

Please Select One ----> Yes No Is someone required to be named as additional insured under your policy?

What is the relationship (example – premises owner for leased property)

Please Select One ----> Yes No Is Care, Custody & Control coverage desired?

If yes, you also need to fill out that application. Care, Custody & Control provides coverage for non owned horses in your care for injury or death if you are found negligent.

See detailed information included with liability coverage information. Complete Care, Custody & Control Application which provides cost at various limits.