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

COMMERCIAL GENERAL LIABILITY QUESTIONNAIRE FOR
INDEPENDENT COACHES & INSTRUCTORS
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.
 
IS THIS THE FULL-TIME OCCUPATION/ACTIVITY OF THE APPLICANT?
    If NO, please explain
PLEASE PROVIDE THE FOLLOWING INFORMATION FOR YOURSELF AND ALL OTHERS INSTRUCTING ON YOUR BEHALF (separately):
    Date of birth;
    Total years of experience as instructor;
    Current qualifications for riding instruction
DO YOU HAVE CURRENT EC ACCREDITATION?
    If YES, what level? EC Membership#
DO YOU OWN A TRUCK AND HORSE TRAILER?
    What is the maximum number of horses that can be transported at any one time?
DO YOU TRANSPORT HORSES FOR OTHERS?
    If YES, how often annually?
    If YES, how many? Average value: $
DO YOU BOARD HORSES?
    If YES, how many maximum?
    What is the average value of boarded horses?
DO YOU TRAIN HORSES?
    If YES, how many... owned: non-owned:
TOTAL NUMBER OF STUDENTS?
HOW MANY STUDENTS DO YOU INSTRUCT AT ANY ONE TIME?
DO YOU OWN OR LEASE HORSES USED FOR RIDING INSTRUCTION?
If YES, how many (max)?
DO YOU OWN ANY HORSES NOT USED FOR RIDING INSTRUCTION?
    If YES, how many (max)?
    Please describe activity/use:
TYPE OF LESSONS: 
DO YOU PROVIDE RIDING INSTRUCTION TO THE PHYSICALLY OR MENTALLY HANDICAPPED?
    If YES, please indicate...
 number of students: age of students:
    number of sidewalkers: instructors:
    LIST QUALIFICATIONS, EXPERIENCE AND AGE OF:
      Instructor(s):
      Horse(s):
    DO THESE CLIENTS COME AS INDIVIDUALS OR AS PART OF A GROUP (name group)?
IS A RELEASE SIGNED BY ALL STUDENTS, PUPILS, OR IF A MINOR, BY A PARENT/GUARDIAN BEFORE INSTRUCTION?
**NOTE: Please attach a copy of the release used.**
DO YOU JUDGE, COURSE DESIGN, STEWARD OR OFFICIATE AT ANY NON-EQUINE CANADA HORSE SHOWS?
    If YES, are you 'carded' or otherwise accredited? (name accreditation)
DO YOU ORGANIZE OR OPERATE HORSE SHOWS ?
    How many annually? Length of show:
    Where are the shows held?
DO YOU ORGANIZE OR OPERATE CLINICS ?
    How many annually?
    Where are the clinics held?
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?
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?
 
 
ARE THERE ANY OTHER ACTIVITIES, OR DO YOU PROVIDE ANY OTHER SERVICE ON THE PREMISES NOT DESCRIBED ABOVE?
    If YES, please describe:
GROSS REVENUE
OPERATION LAST YEAR NEXT YEAR (projected)
    riding instruction
 $ $
    boarding
 $ $
    breeding/foaling
 $ $
    shows
 $ $
    clinics
 $ $
    transport
 $ $
    camps
 $ $
    other
$ $
     
TOTALS $ $
**NOTE: Trail riding and/or rental of horses to the general public on an hourly basis, hay rides, pony rides, sleigh rides, are excluded under this insurance policy.**
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
    D M YEAR