Equestrian Homeowner, Ranch & Estate Program

Farm/Ranch/Equestrian Program

Agency:______
Address:______
______
Phone #: ( )Fax #: ( ) / Policy/Renewal # ______
Producer: ______
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: ڤ Own ڤ Lease
Type of Ownership: ڤ Individual ڤ Corporation ڤ Partnership ڤ Trust ڤ LLC
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? ڤ Yes ڤ No
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? ڤ Yes ڤ No
If yes, explain:
Name and address of Mortgagee:
______
Loan # ______
*Note buildings applicable to. / Name and address of Loss Payee:
______
Loan #
______
*Note buildings/equipment applicable to.
Describe Any Farming Operations Other Than Equine: ______
Gross Annual Receipts: $ ______Contract Labor? ڤ Yes ڤ No
How Is Product Sold? ______
How long has producer known applicant: ______Date producer last inspected the premise: ______

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: ______
Deductible: Dwelling & Farm Structures
ڤ $500 ڤ $1,000 ڤ $2,500
Other: $______/ Name of responding fire department.
Full Time or Volunteer? / Feet from Hydrant / Miles from Fire Department / Other Water Source
Location # /

Main Dwelling

Other Dwellings and Farm Structures

Building Description Diagram #
Primary Residence? / Yes ڤ No ڤ
A. Coverage Amount / $ / $ / $ / $ / $ / $
B. Appurtenant Structures / $ / $ / $ / $ / $ / $
C. Household Contents / $ / $ / $ / $ / $ / $
D. Loss Of Use / $ / $ / $ / $ / $ / $
Covered Causes
of Loss / ڤ Basic
ڤ Broad
ڤ Special / ڤ Basic
ڤ Broad
ڤ Special / ڤ Basic
ڤ Broad
ڤ Special / ڤ Basic
ڤ Broad
ڤ Special / ڤ Basic
ڤ Broad
ڤ Special / ڤ Basic
ڤ Broad
ڤ Special
Loss Settlement / RC ڤ ACV ڤ / RC ڤ ACV ڤ / RC ڤ ACV ڤ / RC ڤ ACV ڤ / RC ڤ ACV ڤ / RC ڤ ACV ڤ
Earthquake Coverage / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Occupancy / ڤ Owner
ڤ Tenant
ڤ Caretaker/Employee / ڤ Owner
ڤ Tenant
ڤ Caretaker / ڤ Owner
ڤ Tenant
ڤ Caretaker / ڤ Owner
ڤ Tenant
ڤ Caretaker / ڤ Owner
ڤ Tenant
ڤ Caretaker / ڤ Owner
ڤ Tenant
ڤ Caretaker
# of Families
Year Built
Type of Construction
Roof: Type
Age
Source
Heating: Type of Furnace
Age
Cooling / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Smoke Alarm
Type of System / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Burglar Alarm / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Central Station Fire Alarm / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Lightning Rods / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yesڤ No ڤ
Fire Extinguishers / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Sprinkler System / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Hay Storage / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Renovation Update:

Year of Update for

Buildings over 25 yrs. / Wiring ______yr.
Heating ______yr.
Plumbing ______yr.
Roof ______yr. / Wiring ____ yr.
Heat______yr.
Plumb_____yr.
Roof ______yr. / Wiring ____ yr.
Heat______yr.
Plumb_____yr.
Roof ______yr. / Wiring ____ yr.
Heat______yr.
Plumb_____yr.
Roof ______yr. / Wiring ____ yr.
Heat______yr.
Plumb_____yr.
Roof ______yr. / Wiring ____ yr.
Heat______yr.
Plumb_____yr.
Roof ______yr.
Wood Stove (see pg 10) / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Mobile Buildings (see pg 4) / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Exposed Urethane Styrene / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ / Yes ڤ No ڤ
Asbestos: Yes ڤ No ڤ Yes ڤ No ڤ Yes ڤ No ڤ Yes ڤ No ڤ Yes ڤ No ڤ Yes ڤ No 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.

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.

Scheduled Farm & Personal Property

Applicant:
Scheduled Property
Deductible: ڤ $500
ڤ $1,000
ڤ $2,500
ڤ $5,000
ڤ Other: / Please list all Tractors, Tractor Implements, Other Farm Machinery, Hay, Irrigation Equipment, Tack & Grooming Equipment, Small Tools & Supplies, Jewelry, Watercraft, Guns, Furs, Fine Arts, Cameras, Coins, Sports Equipment, Silverware, Computers and all other similar items. / Covered Cause of Loss:
ڤ Basic
ڤ Broad
ڤ Special
Type / Description of item, model #, year, and serial number. / Insured Amount
TOTAL FARM & PERSONAL PROPERTY: / $
Mobile Home Tie Down Report
Make of mobile home: ______
Model: ______
Year built: ______
Year Installed: ______/ Please show a diagram of the mobile home including tie downs.
Length of Home / Frame Ties and Anchors per Side / Over Home Ties
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? ڤ Yes ڤ No
Is the mobile home skirted? ڤ Yes ڤ No

Liability Section

Limits and Coverage Options

Each Occurrence Limit
Fire Damage Limit (Any one Fire)
Medical Payments (Any one Person) / ڤ $500,000
$50,000
$5,000 / ڤ $1,000,000
$50,000
$5,000
Products and Completed Operations
Excess Coverage
Excess Limits: / ڤ Yes ڤ No
ڤ Yes ڤNo
$1m ڤ $2m ڤ $3m ڤ $4m ڤ Other ڤ / PLEASE COMPLETE THE UMBRELLA ACORD FORM FOR EXCESS COVERAGE

Does applicant hire any part time or full time workers? If yes, how many PT? ___FT? ___
Does applicant carry Worker Compensation/Employers Liability?
Does applicant have any leased workers?
Does applicant trade or exchange lesson, boarding, or other services for work performed on the applicants behalf?
Does applicant own any rental property?
Is any land held for real estate development or speculation?
Does applicant maintain any vacation or seasonal premises?
Are any portions of the farm rented or leased or used by any other individual, corporation, or other interest for any activities other than farming?
Does applicant grow or store tobacco?
Is farming/equine the major source of applicant’s income? If no, please explain.
Has the applicant ever filed for bankruptcy?
Any paying guests on premises (hunting, fishing, dude ranch, bed & breakfast, resort)?
Is there a swimming pool on premises? Is it fenced? Diving board? Depth? ______
Any other bodies of water on premises? If so, please describe. ______
Any commercial food processing?
Any custom farming? If so, gross annual receipts? ______
Any independent contractors hired to perform any farming operations? If yes, please describe.______
Does the applicant own any recreational vehicles? If so, what type and how many?______Farm use only?
Does the applicant have any camping areas or places where trailers can be parked?
Any non-farming activities such as excavating, snow removal, or other non-farming pursuits?
Does applicant allow the premises to be used for any activities such as snowmobile races, rodeos, roping contests, or other similar recreational use?
Does applicant build, repair, or design machinery, equipment, or systems for anyone for a fee?
Does applicant mix, process, slaughter, butcher, or otherwise prepare for “end consumer” his or any other grower’s product? If yes, please describe and provide receipts______

Y ڤ N ڤ

Does applicant handle any product, such as seed, fertilizer, or sprays for resale?
Any contract service operations performed for others such as tilling, excavating, or ditching?
Are farm premises open to the public for roadside stands, u-pick, rent-a-garden, auction, sales, food or beverage service, or Christmas tree sales?
Is there any unusual hazard such as (but not limited to) open dump pits, silage pits, or sump holes?
Is there an airstrip on premises? If yes, please describe type of use, who uses, and frequency.______
Is there a trampoline on premises?
Any business enterprises or professional offices on any of the described premises?

Description______

31.Does applicant lease any part of the land, buildings, stables, and stall space, operations to others?

32.Are all livestock areas completely fenced?

33.Is there a telephone on premises?

34.Does applicant own/maintain any other animals such as ostriches, emus, chickens, etc? If yes, type & number?______

35.Hunting on premises? If yes, by: ڤ Owners? ڤ Others? Does applicant charge a fee?

36.Does applicant own/maintain dogs? If yes, how many and what breed(s)? If mixed, please indicate breeds______

37.Has any dog which applicant owns or on applicants premises bitten or caused injury to anyone? If yes, when?______

For all food producers, please go this website for important compliance information:

Remarks:

______

Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ
Y ڤ N ڤ /

Does applicant build, repair, or design machinery, equipment, or systems for anyone for a fee? Y ڤ N ڤ
Does applicant mix, process, slaughter, butcher, or otherwise prepare for “end consumer” his or any other grower’s product? If yes, please describe and provide receipts. Y ڤ N ڤ
Does applicant handle any product, such as seed, fertilizer, or sprays for resale? Y ڤ N ڤ
Any contract service operations performed for others such as tilling, excavating, or ditching? Y ڤ N ڤ
Are farm premises open to the public for roadside stands, u-pick, rent-a-garden, auction, sales, food or beverage service, or Christmas tree sales? Y ڤ N ڤ
Is there any unusual hazard such as (but not limited to) open dump pits, silage pits, or sump holes? Y ڤ N ڤ
Is there an airstrip on premises? If yes, please describe type of use, who uses, and frequency. Y ڤ N ڤ
Is there a trampoline on premises? If yes, are persons other than household member allowed use? Y ڤ N ڤ
Any business enterprises or professional offices on any of the described premises? Y ڤ N ڤ
Does applicant lease any part of the land, buildings, stables, stall space, operations to others? Y ڤ N ڤ
Are all livestock areas completely fenced? Y ڤ N ڤ
Is there a telephone on premises? Y ڤ N ڤ
Do you own/maintain any other animals such as ostriches, emus, chickens etc? If yes, how many? Y ڤ N ڤ
Hunting on premises? If yes, by: Owners, Others? Do you charge a fee? Y ڤ N ڤ
Do you own/maintain dogs? If yes, how many and what breed(s)? If mixed, please indicate breeds. Y ڤ N ڤ
Has any dog which you own or on your premises bitten or caused injury to anyone? If yes, when? Y ڤ N ڤ
Does the applicant own any recreational vehicles? If so, what type and how many? Y ڤ N ڤ
Any independent contractors hired to perform any farming operations? If yes, please describe. Y ڤ N ڤ
Any custom farming? If so, gross annual receipts? Y ڤ N ڤ

Remarks: ______

Equine Commercial General Liability

ڤ PLEASE CHECK HERE IF THERE ARE NO OWNED OR NON-OWNED 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?
Emergency numbers posted?
Safety and Barn Rules Posted?
Current liability waivers utilized?
Boarding/Breeding/Training agreements?
Smoking allowed in barns?
Shoes with heels required?
State Equine Liability Signs posted? / Yes ڤ
Yes ڤ
Yes ڤ (Enclose copies)
Yes ڤ (Enclose copies)
Yes ڤ (Enclose copies)
Yes ڤ
Yes ڤ
Yes ڤ / No ڤ
No ڤ
No ڤ
No ڤ
No ڤ
No ڤ
No ڤ
No ڤ / Helmets are Required:
ڤ By everyone all of the time
ڤ 18 and under all of the time
ڤ Everyone while jumping
ڤ Only under 18 while jumping
ڤ Never required
Describe precautions to keep horses from having access to public roads:

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 / ڤ Yes ڤ No / Total Clinic Days: ______# Participants per day: ______
Off Premises Riding Clinics / ڤ Yes ڤ No / Total Clinic Days: ______# Participants per day: ______
Hosted Shows/Events / ڤ Yes ڤ No / # Sanctioned Shows:______# Non-Sanctioned Shows_____
PLEASE NOTE: COVERAGE IS NOT PROVIDED FOR “BODILY INJURY” TO ANY PERSON WHILE PRACTICING 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: ______
Number of Spectators at any one Event: ______
Grand Stands ڤ Yes ڤ No
Maximum Seating ______Construction Type______/ List all show dates: ______
______
______
All dates must be declared before actual event date.
Concession stand on premises?
What type of sales? ______
Any liquor sold? / ڤ Yes ڤ No
ڤ Yes ڤ No
ڤ Yes ڤ No
Tack Store/Retail Sales
Any used tack sales? / ڤ Yes ڤ No
ڤ Yes ڤ No / (Tack repair not eligible.) Total annual Gross tack sales: $______

Pony & Horse Drawn Vehicle Rides

/ ڤ Yes ڤ No
Horse Sales / ڤ Yes ڤ No / Total Owned & Non-owned horses sold annually______
Independent Trainers/Instructors / ڤ Yes ڤ No / (If yes, please complete the Independent Form on page 9.)
Do you provide riding for the handicapped? / ڤ Yes ڤ No / Do you provide any farrier services?
If yes, on premises only? / ڤ Yes ڤ No
ڤ Yes ڤ No
Do you provide horse rentals or offer trail rides? / ڤ Yes ڤ No / Farrier Receipts:______
Number of carts/buggies/wagons owned/used in public events / ______/ Riding Facilities:
Arena: ڤ Indoor ڤ Outdoor ڤ Open Fields ڤ Trails
Care Custody & Control

Is Care, Custody and Control Coverage desired? (If yes, indicate limit below.) ڤ Yes ڤ No

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

Minimum number of non-owned horses in your care ______
Maximum number of non-owned horses in your care ______
Minimum value of non-owned horses in your care ______
Maximum values of non-owned horses in your care ______
Average number of non-owned horses in your care ______
Average value of non-owned horses in your care ______
What type of fencing is used in runs, pastures, and paddocks?______
Is wire utilized in the construction of pasture fences, paddocks or any area that non-owned horses will have access? Y ڤ N ڤ

Type of fencing?______

Are shelters provided in runs or pastures? If yes, please describe.______Y ڤ N ڤ
Where are non-owned horses kept at night (stable, pasture, etc.)?______
Is smoking allowed within structures? Y ڤ N ڤ
Are stallions housed, pastured and exercised in

separate pastures, paddocks and runs,

away from mares? Y ڤ N ڤ

Do all electrical lights have explosion proof covers? Y ڤ N ڤ
Are electrical outlets inaccessible to horses? Y ڤ N ڤ
Does applicant mix own concentrate feed rations

on the premises? Y ڤ N ڤ

Is feed stored in the stabling area? Y ڤ N ڤ
Is the feed room secured with horse proof latches? Y ڤ N ڤ
What is the construction and type of stalls?______
Size of stalls (sq. ft. & height)?______
Do you require the owner(s) to provide health statements prior to accepting the non-owned horses? Y ڤ N ڤ
Explain emergency procedures if horse is ill and the owner cannot be contacted:______
Are all non-owned horses required to have permanent methods of identification, i.e. tags, brands, tattoos, registration records? If yes, explain. Y ڤ N ڤ

______