Private Horse Owner Application Form
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1
2Private Horse Owner Application
P.O. Box 2009, Glen Allen, VA 23058-2009 Phone: (800) 262-7535 Fax: (804) 527-7784
Web site: Email:
This policy provides coverage for bodily injury and property damage only done by a horse which is scheduled on this policy both on
and off premises. If applicant is involved in commercial equine operations*, or if applicant owns more than 10 horses, complete a
Commercial Equine Liability application for appropriate coverage.
∗Commercial Equine Operations: where the applicant is actively involved in the breeding, boarding, training of horses, riding
instruction, leasing of horses to others and any activity that receives money or other compensation.
NOTE: Coverage cannot be bound until the Company approves your completed application. The Company’s receipt of
premium does not bind coverage until a written quote has been issued.
Broker Name: _____________
Broker Number: ________
Applicant: _____________________________________
Business Name: ________________________________
Company Name: __________________________________
Mailing Address: ________________________________
Mailing Address: __________________________________
City:_______________ County: ___________________
City:
State: _____ Zip Code:_________
State:
Zip Code:_________________
Phone #: (___)__________ Fax #: (___) ___________
Phone #: (___) ____________ Fax #: (___) __________
Contact Person:__________ Contact Phone #:________
Email Address: ___________________________________
Email: ________________________________________
Section 1 - Applicant Information
Desired Effective Date:____________________
1. a. Type of Ownership:
Corporation
Individual∗
Joint Venture
Limited Liability Company
Trust
Organization
Partnership
None
b.∗If applicant shows multiple individual names, what is the relationship of applicant(s):
Husband/Wife;
Parent/Child;
Siblings;
Other: ____________________________________
2. Names of corporate partners/officers: ___________________________________________________
3. Is applicant a member of:
AHA
AQHA;
APHA;
ARIA;
NRCHA;
NRHA;
USDF;
USEF;
USHJA
Other:_________
None
4. a. Date of birth of applicant: ___________________________
b. Describe applicant’s experience with horses:
_______
5. a. Is applicant’s primary residence:
owned or
rented?
b. Where are applicant’s horses boarded:
owned premises;
rented premises;
racetrack;
training/boarding facility;
other:__________________________
c. Are there any other operations conducted on owned/rented facility? If yes, explain on a separate page.
Yes
No
6. Do any applicant’s horses have any evidence of behavioral vices or habits?
If yes, explain on separate page.
Yes
No
7. a. Does applicant own or use carts or buggies with their horses?
Yes
No If yes, number of carts or buggies:____
b. Carts are used for:
pleasure;
pulling;
show;
racing;
other: ____________________________
8. Would applicant like coverage for horses that travel outside the U.S.?
Yes
No
If yes, list the countries applicant would like covered:________________________ (Additional premium will apply.)
If applicant answers yes to any questions 9-13, complete a Commercial Equine Liability application.
9.
Does applicant lease owned horses to others?
Yes
No
10. Training of applicant’s horses:
a. Does applicant personally train their own horses?
Yes
No
b. Does an Independent Trainer∗ train applicant’s horses?
Yes
No
∗Provide proof of coverage with an “A” rated admitted carrier with equal or greater liability limits as applicant.
c. Horses are trained for:
dressage;
hunting and/or jumping;
racing;
show;
other: ________________
11. Does applicant or anyone else give riding instruction on applicant’s horses?
Yes
No
12. Does applicant breed horses
owned or
not owned by applicant ?
Yes
No
If yes to breeding, download and complete the Private Horse Owner Supplement from our website or contact our office.
13. Are any horses which applicant does not own stabled or pastured at applicant’s premises?
Yes
No
Section 2 - Prior 3 Year Property & Liability Insurance Information
Must be completed in full in order to receive a quote. Including homeowners, renters and business owners’ policies.
Company
Effective Dates
Premium
No. of Claims
Amount Paid
1. a. Has applicant been canceled or refused coverage in the last 5 years? (Not applicable in Missouri.)
Yes
No
b. If yes, please explain: __________________________________________________________________________
2. Explain losses/incidents within the past 5 years with dates and details of loss, including amount paid, on separate page.
None
3. Has the applicant ever filed for bankruptcy or had a foreclosure?
Yes
No
Explain: _________________
App-PHO Agent (Revision 8/5/2009)
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