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

COMMERCIAL GENERAL LIABILITY QUESTIONNAIRE FOR
HORSE SHOWS
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:
 
ADDRESS OF SHOW PREMISES:
    STREET ADDRESS:
    CITY:
    POSTAL CODE:
    PROVINCE:
    BUSINESS PHONE NUMBER:            HOME PHONE NUMBER:    
    FAX:            EMAIL ADDRESS:    
 
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.

    Include: Age; Smoke/Fire Alarms/Extinguishers; #of Stalls; Lightning Rodded?; Heated in Any Area? How?
 
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:
IS THERE AN INDOOR ARENA ON THE PROPERTY? Dimensions:
IS THERE A SWIMMING POOL ON THE PROPERTY?
dimensions: depth: use:
IS THERE A POND ON THE PROPERTY?
dimensions: depth: use:
WHO IS RESPONSIBLE FOR THE MAINTENANCE OF BUILDINGS, FENCING, ETC.?
 
HOW MANY YEARS HAS THE SHOW OPERATED... AT THIS LOCATION? ... AT OTHER LOCATIONS?
 
WHAT DATES WILL THE SHOW RUN THIS YEAR?
WHAT ARE THE DATES OF YOUR OCCUPANCY AT THE PREMISES FOR THE SHOW (move in and move out dates of competitors included)?
HOW MANY SHOWS DO YOU OPERATE ANNUALLY?
THIS SHOW IS A:
ARE YOU HIRING JUDGES OR OTHER OFFICIALS FOR THE SHOW?
    If Yes, are they carded?
DO YOU PROVIDE STABLING FOR COMPETING (OUTSIDE) HORSES?
    If Yes, where are they stabled?
    If Yes, do you provide 24 hour security?
HOW MANY COMPETITORS ARE EXPECTED?
HOW MANY MEMBERS OF THE GENERAL PUBLIC ARE EXPECTED?
IS THERE AN ADMISSION CHARGE TO THE SHOW?
    If yes, what are the gross receipts from the gate?
WHAT CLASSES DO YOU OFFER AT THE SHOW?
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?
**NOTE: This insurance policy does not cover the service or provision of alcohol. If you require this coverage, please contact our office for a separate quote.**
WILL THERE BE A DANCE OR BANQUET IN CONJUNCTION WITH THE SHOW?      
ARE THERE ANY OTHER ACTIVITIES RUNNING IN CONJUNCTION WITH OR AT THE SAME TIME AS THE SHOW?
    If YES, please describe:
ARE YOU LEASING ANY EQUIPMENT (timers, seating, jumps, etc.)?
    If YES, please describe:
**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