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FARM/RANCH INSURANCE

Complete Information below for a more accurate quote

How did you hear about us?

List of other sources

Farm/Business Name

Name

Address

City

State

Zip Code

Phone

Fax Number

Contact Preference

Phone

Mail

Click here to learn more about Farm/Ranch Insurance

How many Acres?

Nearest Fire Department

Distance to nearest Fire Hydrant?

Owner Occupied?

Yes

Tenant Occupied?

Yes

Replacement Cost Value of Main Dwelling

Year Built

Square Footage

Type of Construction

Type of Roof (shingles, metal, etc)

Description:

Personal Property to be insured?

Farm Personal Property to be insured?

Instructions

Include Stables, Barns, Hay Storage Buildings, Equipment Storage, Run-In-Sheds, etc.

Structure 1 Type:

Replacement Cost Value

Year Built

Square Footage

Type of Construction

Type of Roof (shingles, metal, etc)

Barn/Stable

Hay Storage in any building?

Smoke/Burglar Alarms in any buildings?

Yes

Fire Extinguishers in any buildings?

Yes

Lightning Rods on any structure?

Yes

Sprinkler System in any structure?

Yes

Wood burning stove in any structure? (Main source of heat?)

Yes

Do you have another structure?

Structure 2 Type:

Replacement Cost Value

Year Built

Square Footage

Type of Construction

Type of Roof (shingles, metal, etc)

Barn/Stable

Hay Storage in any building?

Smoke/Burglar Alarms in any buildings?

Yes

Fire Extinguishers in any buildings?

Yes

Lightning Rods on any structure?

Yes

Sprinkler System in any structure?

Yes

Wood burning stove in any structure? (Main source of heat?)

Yes

Do you have another structure?

Structure 3 Type:

Replacement Cost Value

Year Built

Square Footage

Type of Construction

Type of Roof (shingles, metal, etc)

Barn/Stable

Hay Storage in any building?

Smoke/Burglar Alarms in any buildings?

Yes

Fire Extinguishers in any buildings?

Yes

Lightning Rods on any structure?

Yes

Sprinkler System in any structure?

Yes

Wood burning stove in any structure? (Main source of heat?)

Yes

Do you have another structure?

Structure 4 Type:

Replacement Cost Value

Year Built

Square Footage

Type of Construction

Type of Roof (shingles, metal, etc)

Barn/Stable

Hay Storage in any building?

Smoke/Burglar Alarms in any buildings?

Yes

Fire Extinguishers in any buildings?

Yes

Lightning Rods on any structure?

Yes

Sprinkler System in any structure?

Yes

Wood burning stove in any structure? (Main source of heat?)

Yes

Select Coverage Limit:

$500,000 per occurrence/$1,000,000 aggregate

$1,000,000 per occurrence/$2,000,000 annual aggregate

Excess over $1,000,000 – Provide Limit required below:

Provide limit required

Describe your Horse Operation.

Total Number of Horses you OWN or LEASE

Total Number of NON-OWNED Horses in your care

Describe fencing and security measures to prevent horse(s) from having access to public roads.

Maximum Number of Horses (owned or non-owned) that can be kept on the premises?

Click here for Care Custody & Control Liability Insurance

What is the total number of Stallions (owned or non owned) standing stud?

# On Premises

# Off Premises

Average Stud Fee Charged

How many mares are bred annually on the premises?

How many owned mares are bred annually off the premises?

How many Non-Owned mares kept on your premises until foaling?

What is the Minimum Number of horses boarded monthly?

Maximum Number of horses on Full Board monthly?

Maximum Number of horses on Pasture/Partial Board monthly?

Full Board Fee

Pasture/Partial Board Fee

List the Type of instructions provided:

Provide details of Safety Gear Required.

Anyone under 21 giving riding instructions?

Yes

Maximum Number of Lesson Horses Available.

Number of Lesson Horses used at any one time.

Total instructions given weekly on Lesson Horses

Total instructions given weekly on Client Owned Horses.

Average Cost per lesson.

Are Stallions used for instructions?

Yes

Do you provide instructions to the handicapped or operate a Therapeutic Equine Program?

Yes

If yes:

You must complete Therapeutic Equine Program Supplemental form

Do you attend off premises shows with your students?

Yes

How Many per year

Charge per show

Are independent instructors part of your riding program?

Yes

Name, Age, Experience of Independent Instructor

Do you hold equine day camps?

Yes

If Yes:

You must complete Equestrian Day Camp Supplemental form

Do you have On-Premises Horse Clinics?

Yes

Total Number of Clinic Days

Number of participants

Charge for Clinics

Description of Clinics

Dates Scheduled

Do you have Off-Premises Horse Clinic?

Yes

Total Number of Clinic Days

Number of participants

Charge for Clinics

Description of Clinics

Dates Scheduled

Will the owner of the premises where the clinic is held be required to be named as an additional insured with respect to the clinics conducted on their property? Provide Name, Address of premises owner

Average number of horses in full training, monthly

Average number of rides weekly on horses NOT in full training

Do you have an Independent Trainer operating on your premises?

Name, Age, Experience of Independent Trainer

Do you host equine related events on your premises?

Yes

Description of equine event (Horseshows, Educational Clinics, etc.)

Scheduled Dates

How many event days per year?

Average number of participants?

Average number of spectators?

Breed of Horses

Avg. # of Owned Horses sold per year

Avg. price of horses sold

Avg. # of Non-Owned Horses sold per year

Avg. price of non-owned horses sold

Is prospect allowed to test ride

Yes

Where on Premises?

Copies of these documents will be required upon placement of your liability insurance.

Do boarders & students sign liability waivers?

Yes

Is everyone provided with safety & barn rules?

Yes

Do you have your State Equine Law posted?

Yes

Do you rent your arena or facility to others?

Yes

Do you operate a tack store or sell tack?

Yes

Do you offer Pony Rides?

Yes

if answer yes:

Please complete Pony Rides Supplemental Application

Do you offer Horse Drawn Vehicle Rides?

Yes

if answer yes:

Please complete Horse Drawn Vehicle Rides Supplemental Application

Is anyone other than a boarder allowed to ride on your premises?

Yes

Do you repair riding equipment?

Yes

Do you perform any type of farrier service?

Yes

Is hunting allowed on the premises?

Yes

Is there a swimming pool on the premises?

Yes

Do you own dogs?

Yes

How Many?

Breed?

Any prior problems?

Yes

Are other dogs allowed on your premises?

Yes

Any other animals on the premises?

Yes

If so describe, giving numbers

Provide details of any other equine activities not included above.

Name of Insurance Company

Expiration date of current policy?

Does your current policy include Equine Liability?

Yes

Any prior losses?

Yes

Have you had any prior insurance cancelled or non renewed?

Yes

Comments / Questions

With the information you have provided in this questionnaire, we will submit an application to the insurance companies we represent to obtain the most competitive quote for your Farm Property & Liability Quote. The quote and the application will be sent to you for review and signing should you want the insurance placed.

Questions? Call Smith-Embry Insurance Associates, Inc. (502) 493-9911