Equestrian Farm Ranch Program

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1 Equestrian Farm Ranch Program The Equestrian Group P.O. Box 9958 Phoenix, AZ (602) FAX (602) Policy # Producer: Phone: Desired Effective Date: Desired Expiration Date: Fax: umber: Applicant: Social Security umber (s): Farm ame / DBA: Mailing Address: City: State: Zip: County: Phone: umber of Acres: Location if different from above: Fax: City: State: Zip: County: Does Applicant: Own Lease Type of Ownership: Individual Corporation Partnership Association Pay Plan Desired? o es Two-Pay Three-Pay Four-Pay Past and/or current Insurance: Company: Annual Premium: HAVE OU HAD A CLAIMS AD/OR REPORTED ICIDETS I THE PAST 3 EARS? o es Explain all claims and reported incidents for the past three-year period. Give dates, cause of loss, amounts paid: Have you had coverage cancelled or refused in the past three years? o es If yes, explain: ame and address of MORTGAGEE: ame and address of LOSS PAEE: * ote buildings applicable to * ote buildings applicable to Remarks: How long has producer known the applicant: Date producer last inspected the premises: Page 1 of 8

2 Applicant: The Equestrian Group : Building Coverage Form PLEASE USE A SEPARATE PROPERT COVERAGE FORM FOR EACH LOCATIO WITH STRUCTURES TO BE ISURED. Location: If different from page 1, location #: Acres: Street: City: State: Zip: County: DEDUCTIBLE: Dwellings & Farm Structures Other: $ Building / Diagram # umber Use or Description MAI DWELLIG ame and department number of the nearest Fire Station. Feet from Hydrant OTHER DWELLIGS AD FARM STRUCTURES A. Coverage Amount $ $ $ $ $ $ B. Appurtenant Structures $ C. Household Contents $ D. Loss of Use Loss Settlement Earthquake Coverage Min. 2 % Deductible ear Built Covered Causes of Loss $ ELITE Miles from Fire Department 10% 20% 10% 20% 10% 20% 10% 20% 10% 20% RC ACV RC ACV RC ACV RC ACV RC ACV RC ACV Occupancy Owner Owner # of Families Type of Construction Owner Owner Owner Owner Roof: Heating: Cooling Smoke Alarm Type of System Burglar Alarm Type of System Type Age Source Type of Furnace Age Lightning Rods Fire Extinguishers Sprinkler System Hay Storage Renovation Update: ear of update for Buildings over 25 yrs. Wood Stove Mobile Buildings Wiring Heating Plumbing Wiring Heating Plumbing Wiring Heating Plumbing Wiring Heating Plumbing Wiring Heating Plumbing FILL OUT WORKSHEET FOR ALL THE QUESTIOS BELOW ASWERED WITH ES. Wiring Heating Plumbing Exposed Urethane Styrene 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 Page 2 of 8

3 The Equestrian Group : Property Diagram Applicant: Location # PROPERT DIAGRAM FOR EACH LOCATIO WITH ISURED BUILDIGS Show all buildings on premises (whether or not insured). Show distance in feet in between buildings. Label all buildings and attach dated photographs. Label C if not covered. Show nearest Road, Highway, or Interstate. Show any Lakes, Rivers, or Ponds. Show Fire Hydrant if applicable. Show Fuel Tank locations. MUST ICLUDE CURRET PHOTOS OF ALL BUILDIGS Page 3 of 8

4 Applicant: The Equestrian Group : Scheduled Personal Property SCHEDULED PERSOAL PROPERT Description Type A. Money B. Securities C. Watercraft D. Trailers E. Sports Equipment F. Fine Arts G. Theft of: Jewelry Per Item Per Occurrence Furs Silverware Guns Per Item Per Occurrence H. Motorized Vehicles (Residential Use Only) I. Grave Markers J. Computers (Hardware & Software) K. Business Property On Premises Off Premises L. Electronic Devices FO-2 $ 100 FO-3 ELITE FO-5 $ 2,000 $ 3,000 $ 10,000 $ 10,000 $ 1,500 / A / A $ 250 / A / A Type Description of item, model #, year, and serial number. Insured Amount Total Scheduled Personal Property Page 4 of 8 $

5 Applicant: The Equestrian Group : Scheduled Farm Personal Property FARM PERSOAL PROPERT: Deductible: Other: Mini Blankets: Basis of Valuation for Business Property: Actual Cash Value The following groups can be listed without listing individual items. Individual items must not exceed per item. A. Tack, Grooming Equipment: Saddles, bridles, tack trunks, grooming equipment, blankets, etc. B. Small Tools & Supplies: Small lawn mowers, chain saws, weed eaters, power tools, hand tools, etc. C. Office Equipment: Computers (hardware & software), phone systems, copiers, fax machines, etc. D. Barn Contents: Furniture, washer & dryer units, other domestic appliances, etc. Covered Cause of Loss: Basic Broad Special Insured Amount Schedule below all Tractors, Tractor Implements, Other Farm Machinery, and all items valued over $2, Description and Model ear Serial umber ote: Hay & Grain Coverage provided OL while stored in a building. Total Scheduled Farm Personal Property $ Insured Amount Page 5 of 8

6 Liability Section LIMITS AD COVERAGE OPTIOS Comprehensive Personal Liability es o Equine Commercial General Liability es o Each Occurrence Limit $300,000 $500,000 $1,000,000 Fire Damage Limit (Any one Fire) $50,000 $50,000 $50,000 Medical Payments (Any one Person) $5,000 $5,000 $5,000 Products and Completed Operations es o Personal Endorsement es o Double Aggregate es o Professional Endorsement es o Excess Coverage es o Excess Limits: $1m $2m $3m $4m List Additional Insureds with relationship descriptions. (Independent Instructors / Trainers and Employees are ot Qualified.) 1. ame: Relationship: 2. ame: Relationship: 3. ame: Relationship: 4. ame: Relationship: Remarks: DEFIITIOS AD ISTRUCTIOS COMPREHESIVE PERSOAL LIABILIT: Personal Homeowner s Liability. (Does not provide coverage for Equestrian Activities.) Primary residence must be insured to qualify. COMMERCIAL GEERAL LIABILIT: Coverage for Commercial Equine Activities which are both declared and approved on the application. PERSOAL HORSE OWER S COVERAGE: Provides coverage for personal, non-commercially owned pleasure horses both on and off premises. EQUESTRIA PROFESSIOAL COVERAGE: Professional Equestrian Errors and Omissions coverage. DOUBLE AGGREGATE: Doubles the amount of coverage that is available during the policy period, but does not increase the occurrence limit. EXCESS LIMITS: Increases the per occurrence and aggregate limit. Primary limits of 1mm per occurrence and 2mm aggregate are required. ADDITIOAL ISUREDS: 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 Insureds. Independent Instructors / Trainers and Employees are not qualified. (An Employee is an insured while working within their job description.) IDEPEDET TRAIERS / ISTRUCTORS: List all Riding Instructors and Trainers who utilize your facility. On Premises 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, CUSTOD & COTROL: CCC coverage is to protect you in the 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 O Coverage provided under the Commercial General Liability for other people s horses in your care. Remember: If you have activities which are not described within the application, they must be listed with explanations, volume of activity, and revenues for coverage to be considered. Page 6 of 8

7 Summary of Equestrian Activities Total number of horses owned / leased by you or your business: Maximum number of horses owned / leased taken off premises (horse shows etc.): Maximum number of horses used for Riding Instruction / School Horses: Give a brief description of operation: Total professional years in this type of an operation: Briefly list officiating, judging, instructors licenses and/or competition experience: If you are not the primary manager, Manager s ame: Age: ears Exp: Any claims in the last three years es Enclose full details o 24-hour supervision of facility es o Emergency numbers posted es o Safety & Barn Rules posted and written out es Enclose Copies o Current liability waivers utilized es Enclose Copies o State Equine Liability signs posted es o Smoking allowed in barns es o Shoes with heels required es o Helmets are Required: By everyone ALL OF THE TIME 18 and under ALL OF THE TIME Everyone while jumping/speed work Only 18 and under while jumping Optional Describe precautions taken to keep horse (s) from having access to public roads: Coverage will be provided only for exposures Marked es Breeding es o Stallions owned: Total mares covered annually: Boarding es o Average number of horses boarded monthly: Horse Sales es o Total horses sold annually: Training es o Average number of horses in training monthly: Independent Trainers es o (Must be 18 years old.) 1. ears Exp. 3. ears Exp. 2. ears Exp. 4. ears Exp. Riding Instruction es o Anyone under 21 giving riding instruction: es o Type of instruction: Operation s Total Riding Instruction, both On and Off Premises, including all Independents On Premises Instruction. Total lessons given annually: Average number of weekly lessons given on CLIET S OW HORSE(S): Average cost per lesson: $ Average number of weekly lessons given on SCHOOL/ISURED S HORSE(S): On Premises Riding Clinics es o Total Clinic Days: umber of participants per day: Off Premises Riding Clinics es o Total Clinic Days : umber of participants per day: Independent Instructors es o (Must be 18 years old.) 1. ears Exp. 3. ears Exp. 2. ears Exp. 4. ears Exp. Officiating/Judging es o Total show days Judging / Officiating annually: Host Shows / Events es o Average number of competitors per Show / Event: Average number of spectators per Show / Event Day: Hosted Sanctioned Show Days per year: Maximum number of competitors: Maximum number of spectators: Sanctioning Organization(s): Hosted on-sanctioned Show Days per year: Maximum number of competitors: Maximum number of spectators: Type of Shows / Events: Show dates: ote: If dates have not been set, Written otice of the event must be received in our office prior to the show date. Coverage is not provided for show dates that have not been declared to the company in advance of the event. Page 7 of 8

8 Tack Store / Retail Sales es o (Tack manufacture and repair not eligible.) Pony & Horse Drawn Vehicle Rides es o (If yes, the Pony Ride / Horse Drawn Vehicle Rides Supplemental Form must be completed.) Do you own dogs? es o If yes, how many, what type, and for what purpose: Has any dog which you own or on your premises bitten or caused injury to anyone. (If es, attach details on a separate page.) es o Other animals on premises es o If yes, describe: Hunting on premises? es o If yes, by: Owners Others Do you charge a fee? es o Swimming pool on premises? es o Do you have a security fence around your pool? es o Is CARE, CUSTOD & COTROL (CCC) coverage desired? es o The rates below include Transportation Coverage for transportation of non-owned horses in your care while in Continental U.S. and Canada. (Excludes Licensed Commercial Haulers.) Select from the limits below. Premiums shown are for up to 20 horses. Limit Per Horse Max Limit Per Policy Annual Base Premium Per horse over 20 horses 1) $5,000 $25,000 $ $5.00 2) $5,000 $50,000 $ $8.00 3) $10,000 $50,000 $ $9.00 4) $10,000 $100,000 $ $ ) $15,000 $100,000 $ $ ) $25,000 $100,000 $ $ ) $25,000 $250,000 $ $ ) $25,000 $300,000 $ $ ) $50,000 $300,000 $1, $ ) $100,000 $300,000 $1, $ ) $100,000 $500,000 Submit for Quote 12) $250,000 $500,000 Submit for Quote 13) $500,000 $1,000,000 Submit for Quote If only local transportation coverage is desired, mark o and $100 will be deducted from the total CCC premium. (If you marked o, local transportation coverage will be provided only up to a 100 mile radius from the address shown on the declaration page.) Average number of non-owned horses in your Care, Custody & Control (Breeding, Boarding, Training, etc.): Maximum number of non-owned horses in your Care, Custody & Control (Breeding, Boarding, Training, etc.): Are your horse trailers in good repair and on a proper maintenance program: es o How often and for what reasons do you transport horses for others: LIST TOTAL AUAL GROSS REVEUES Breeding: $ Boarding: $ Horse Sales: $ Training: $ Riding Instruction: $ Riding Clinics: $ Judging: $ Hosting Shows: $ Tack / Retail Sales: $ Pony Rides: $ Horse Wagon Rides: $ Day Camps: $ Other ( ): $ Total Annual Gross Revenue: $ If you have not listed all of your activities and exposures with explanations and revenues, list them here. (REMEMBER: EXPOSURES OT DECLARED ARE OT COVERED.) o FRAUD WARIG: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime. WARRAT 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 part of any policy issued and that the Company requires that I/We obtain additional insured certificates of insurance for independent contractors for coverage to remain in effect. I/We hereby make application to The Equestrian Group and it s Companies for Commercial Equine Liability Insurance. I/We understand any policy issued will not provide Worker s Compensation. The insured assigns as security for the total premium and/or fees payable any and all unearned premiums and dividends which may become payable. I/We agree to pay reasonable attorneys fees, costs and expenses necessarily incurred if suit or collection becomes necessary (not to exceed 50%). APPLICAT S SIGATURE: PRIT: DATE: Page 8 of 8

Race Horse Homeowner, Ranch & Estate Program

Race Horse Homeowner, Ranch & Estate Program Exclusively Underwritten By AMERICAN EQUINE INSURANCE GROUP Note: Producer: Policy and/or Renewal #: Expiration Date: Requested Effective Date: Incomplete applications