Business Name:
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Contact Name
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First Name
Last Name
Email
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Phone
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Business Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Has your coverage ever been Cancelled, Refused or Non-Renewed?
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If Yes, please provide details:
Have you had any claims in the past 3 years?
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If yes, enter all claims or losses (regardless of fault or coverage available/provided) Or occurrences that may give rise to claims
Provide Date of Occurrence / Description of Claim / Paid Amount / Reserve Amount / Claim Status (Open or Closed) for each claim below.
PLEASE NOTE: THE FOLLOWING ARE INELIGIBLE FOR COVERAGE AND WILL BE EXCLUDED UNDER THE POLICY:
What length of policy term are you looking for?
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If Seasonal or Short Term, please provide start date and end date below:
Please describe all operations to be covered:
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Description of your experience operating or working in this type of business:
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WHAT EQUINE EXPOSURES DO YOU OFFER? PLEASE ALSO COMPLETE APPLICATION SECTION BELOW FOR ANY EXPOSURES INDICATED:
All Other Sales - please describe:
Location of Operations:
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IF OFFSITE, PLEASE PROVIDE DETAILS:
Are Waiver & Release forms required for all participants?
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Do you currently have a risk management plan?
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If Pony or Horse riding, are helmets required?
Do you have concussion protocols in place?
Do coaches/trainers receive concussion management training?
Explain All Safety Precautions/Procedures
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Description of any other non-equine exposures you offer:
Do you have any of the following?
If you have any of the above, please provide details:
Provide Types of Horse Drawn Vehicles Used:
Include Description of Vehicle, # of Vehicles and # of Horses (i.e. Carriage/Wagon/Cart/Sleigh/Sled/Other)
Safety Measures in place for Vehicles described above:
Driver Information (Carriage/Wagon/Cart/Sled/Sleigh)
Provide First & Last Name, Age and Years Experience
Are you primarily operating carriage/horse-drawn vehicle rides at events (weddings/parades) or for permanent set routes (tours)?
Please provide description
Are horses or vehicles left unattended when in use?
Are passengers assisted upon entering or exiting vehicles?
Are you required to have a license in the city/state you are operating in?
Type of pony rides that you provide?
If Other, please describe
Do you use any type of pony ride enclosure?
Where are your pony rides occuring?
On Premises, Off Premises - if off premises, please explain
Do you strap children to ponies, saddles or carousel?
Please explain
Is your petting zoo
Do you have a sanitation station?
List Species of all animals in your petting zoo and the # of each:
Estimated number of annual instruction students:
Estimated number of short term camp participants:
Are camps day-only or overnight?
Estimated number of show participants:
Do you attend off-site shows with your students?
Please check all instruction that apply:
Do students use their own horses or stable horses?
Are all trail rides guided?
If no, please provide details:
Are riders pre-screened to determine ability?
Are rides provided during the daylight hours only?
Is anything above a trot allowed?
Do you have any weight or age restrictions?
If yes, please describe in detail:
Are riders under a certain age required to wear a helmet?
Please explain:
ADDITIONAL INSUREDS (Landlord, Venue, Municipality, etc)
PLEASE PROVIDE ENTITY NAME AND MAILING ADDRESS AND A CONTACT EMAIL ADDRESS TO SEND CERTIFICATES TO:
Standard Additional Insureds are added at no cost.
(Special Language/Endorsements/Higher Insurance Limit Requirements may result in a pricing increase)
The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted.
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