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

COMMERCIAL VEHICLE SUPPLEMENT FORM
TO BE COMPLETED AND SIGNED BY THE INSURED. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
CURRENT OR LAST INSURANCE COMPANY:
BROKER:
OWNER DETAILS | COMMERCIALLY USED VEHICLE
NAME OF OWNER(S)*:
STREET ADDRESS*:
CITY*:
POSTAL CODE*:
PROVINCE*:
BUSINESS PHONE NUMBER:
HOME PHONE NUMBER*:
FAX:
EMAIL ADDRESS *:
OWNER DETAILS | COMMERCIALLY USED TRAILER    
NAME OF OWNER(S):
STREET ADDRESS:
CITY:
POSTAL CODE:
PROVINCE:
BUSINESS PHONE NUMBER:            HOME PHONE NUMBER:    
FAX:            EMAIL ADDRESS:    
1. Where is the truck usually kept?      Where is the trailer usually kept?
2. How many horses can your trailer carry?      How many horses do you normally carry?
3. What is the truck primarily used for? (check all that apply)
4. Transportation of Horses: OWNED NON-OWNED
    a) How many times per month do you transport horses?
    b) How many times per month do you transport horses less than 50 km away?
    c) How many times per month do you transport horses more than 50 km away?
    d) Please list the farthest destination to which you transport horses
    e) Do you transport horses to the United States?    
      Number of times per year:     Destination(s):
5. How many years have you owned and operated truck and trailer?    
6. Please list all accidents and/or claims that have arisen from owning and operating a truck in the last 6 years:
    At-fault accidents? Please give details    
    Not at-fault accidents? Please give details    
    Comprehensive losses? Please give details    
7. Is your truck and trailer leased or rented to others?     Yes No
    If Yes, please provide their full name and address:    
8. Is the truck used for "snow removal" or any other commercial exposure other than pulling a horse trailer?     Yes No
    If Yes, please provide details:    
 
SIGNATURE (ENTER YOUR NAME)*: date signed
D M YEAR