Henry Equestrian Insurance Brokers
download printable version For manual submission, download this form here.
 

COMMERCIAL GENERAL LIABILITY QUESTIONNAIRE FOR
EQUESTRIAN CLUBS & ASSOCIATIONS
TO BE COMPLETED AND SIGNED BY THE INSURED. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
IMPORTANT: THIS IS NOT A BINDER. INCOMPLETE AND/OR UNSIGNED APPLICATIONS WILL BE RETURNED.
NAME OF INSURED (to appear on policy)*:
OPERATING NAME*:
STREET ADDRESS*:
CITY*:
POSTAL CODE*:
PROVINCE*:
PRIMARY CONTACT NAME*:
BUSINESS PHONE NUMBER*:
FAX NUMBER:
EMAIL ADDRESS*:
INSURED IS:
 
PROPOSED INCEPTION DATE FOR INSURANCE:
 
NAME ALL PARTNERS AND/OR OFFICERS
 
ADDITIONAL INSUREDS TO BE NAMED ON POLICY (please explain working relationship)
DO YOU OWN / RENT / LEASE PREMISES OR PART THEREOF     
    please provide location, describe building(s) and advise how often used and for what purpose.
 
IF PREMISE(S) IS(ARE) RENTED / LEASED, PLEASE PROVIDE OWNER INFORMATION:
    NAME OF OWNER(S):
    STREET ADDRESS:
    CITY:
    POSTAL CODE:
    PROVINCE:
    BUSINESS PHONE NUMBER:
    HOME PHONE NUMBER:
    FAX:
    EMAIL ADDRESS:
HOW LONG HAS THE GROUP BEEN IN EXISTENCE?
HOW MANY MEMBERS ARE ENROLLED?
DO YOU HOST MONTHLY/REGULAR MEETINGS?      
    If Yes, where are they held?
DOES THE GROUP HAVE AN ANNUAL GENERAL MEETING/BANQUET?      
    If Yes, where?
DO YOU PROVIDE FOOD, BEVERAGES AND/OR ALCOHOL AT ANY SHOW OR CLINIC?      
    If Yes, please provide the breakdown of annual gross receipts:
    Food & Beverage:
    Alcohol:
    Is provided food/beverage catered or homemade?
         
    If alcohol is served, in whose name is the liquor license?
DOES THE GROUP DO ANY FUNDRAISING ACTIVITIES?      
    If Yes, please explain in detail:
WHAT ARE THE ANNUAL GROSS RECEIPTS (FROM ALL SOURCES) PLEASE PROVIDE BREAKDOWN IN GENERATING ACTIVITIES:
HORSE SHOWS
DO YOU ORGANIZE OR OPERATE HORSE SHOWS ON THE PREMISES?
    How many annually? Length of show:
DO YOU ORGANIZE OR OPERATE HORSE SHOWS OFF THE PREMISES?
    How many annually? Length of show:
TYPE OF SHOW(S):
    If Equine Canada Shows, please provide dates required:
from: to:
from: to:
from: to:
from: to:
DO YOU PROVIDE STABLING FOR COMPETING (OUTSIDE) HORSES?
HOW MANY HORSES PARTICIPATE AT THE SHOWS?
WHAT TYPE OF CLASSES DO YOU OFFER AT THE SHOWS?
HORSE CLINICS
DO YOU ORGANIZE OR OPERATE CLINICS ON THE PREMISES?
    How many annually?
DO YOU ORGANIZE OR OPERATE CLINICS OFF THE PREMISES?
    How many annually?
TYPE OF CLINIC: 
HOW MANY PARTICIPANTS AT EACH CLINIC?
ARE THE CLINICIANS INSURED SEPARATELY UNDER THEIR OWN POLICY?
IS A RELEASE SIGNED BY ALL RIDERS / MEMBERS, OR IF A MINOR, SIGNED BY PARENT / GUARDIAN?
Please mail or fax a copy of the release used.
WHAT TYPE OF SAFETY GEAR IS REQUIRED OF ALL RIDERS IN SHOWS, CLINICS, LESSONS, ETC.?
DO YOU PROVIDE ANY OF THE SAFETY GEAR?
    If Yes, how often is it checked?
IS THE GROUP INVOLVED IN ANY OTHER ACTIVITIES?      
(i.e. poker runs, camps, riding instruction, trail rides, etc. [specify if open to public/members])
    If Yes, please detail all activities:
NON-PROFIT SOCIETY ERRORS & OMISSIONS LIABILITY APPLICATION
1. Name of Applicant
    Business Address of Applicant
2. Date of incorporation: Incorporated as: (society, or,...)      
3. (a) Describe organization's purpose and function:
     (b) Number of, Directors:       Officers:       Employees:       Total Members:
4. Affiliated/Subsidiary companies operating for profit?
5. Stockholders or persons who profit from the organization except as salaried employees
6. Are any directors/trustees/officers indebted to the applicant?
7. Source of applicant's funds Public contributions       % other (describe)
8. Within the last 3 years has any suit been brought against the applicant or any director, trustee, officer, or employee thereof?
9. Does any director, trustee or officer have knowledge of any error or omission, breach of duty or other circumstance which might give rise to a suit?
10. Previous directors & officers or errors & omissions liability insurance (None or prior insurer)
11. Has any insurer declined, cancelled, or refused to renew directors & officers or errors & omissions liability insurance?
12. Please mail or fax the following with this application: (a) Schedule of directors, officers, trustees;
(b) Applicants charter or by-laws;
(c) Most recent annual report
List all CLAIMS, POTENTIAL CLAIMS or ACTIONS pending or brought against you or any employee in the last three years
 
HAVE YOU HAD PREVIOUS INSURANCE?    
    If Yes, indicate Company name:
    Indicate policy number:
    Expiry date:
 

I UNDERSTAND THAT THE INSURANCE BEING APPLIED FOR, IF ACCEPTED BY THE INSURING COMPANY, WILL BE BASED ON THE STATEMENTS AND INFORMATION IN THIS APPLICATION.

IF ANY INFORMATION IS WITHHELD OR FALSELY STATED, INSURANCE ISSUED MAY BE SUBJECT TO CANCELLATION OR MODIFICATION AS PROVIDED BY THE LAWS OF THE PROVINCE IN WHICH THE APPLICATION WAS ACCEPTED OR THE POLICY ISSUED.

I CERTIFY THAT THE INFORMATION HEREWITH IS TRUE AND IS A COMPLETE DESCRIPTION OF THE ACTIVITIES THAT I WISH TO INSURE AND FURTHER, THAT ALL CLAIMS INFORMATION AS REQUESTED HAS BEEN COMPLETELY DISCLOSED.
 
    SIGNATURE (ENTER YOUR NAME)*: date signed
    TITLE: D M YEAR