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Equine Risk Evaluation
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Insured 1 - First Name
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What is your first name? *
Insured 1 - Last Name
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What is your last name? *
Insured 1 - Phone Number
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What is your preferred phone number? *
Email
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Please enter your email. *
Please enter the location address.
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Please enter your primary home address. *
Street Address
Address Line 2
City
State
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American Samoa
Arizona
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Connecticut
Delaware
District of Columbia
Florida
Georgia
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Maryland
Massachusetts
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New Hampshire
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New York
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North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Equine Ownership Details
Reasons for Horse Ownership
Please select the option(s) that best describes your horse ownership. (Select all that apply)
Own/ride horses for pleasure
Own/ride horses for personal competition
Own/ride horses as part of a farm operation
Other
Horse Ownership Other
Please provide a brief description of your horse ownership.
Number of Owned Horses
How many horses do you own?
Horse Disciplines
Please select the disciplines your horses are involved in.
Pleasure
Arabian Show
Eventer
Hunter/Jumper
Dressage
Racing
Steeplechase
Saddlebred
Breeding
Western
Other
Horse Disciplines - Other
Please enter the other disciplines your horses are involved in.
Horse Ownership Structure
Please select the ownership structure for your horses.
Owned Personally
Owned in a Trust, LLC, or LLP
Horse Owning Entity Name
What is the legal name of the trust, LLC, or LLP that owns the horses?
Horse Boarding Location
Where are your horses boarded?
Primary Home
A Farm I Own
A Farm or Facility I Do Not Own
Horse Rider Names
Please enter the names of the people who ride your horses.
First
Last
Horse Trainer Names
Please enter the names of the people who train your horses.
First
Last
Horse Competitor Names
Please enter the names of the people who compete with your horses.
First
Last
Horses Leased or Used by Others
Are any of your horses leased to or used by third parties?
Yes
No
Leasing/Third Party Use Details
Please provide an overview of the leasing/third party use of your horses.
Number of Leased Horses
How many horses are leased or used by third parties?
Leasing Agreement in Place?
Is a leasing agreement used whenever horses are leased to others?
Yes
No
Lease Agreement Indemnification Clause
Does the leasing agreement contain an indemnification clause?
Yes
No
Income Generated from Horses?
Do you generate income from your horse ownership?
Yes
No
Horse Gross Income
What is the estimated annual gross income generated?
Horse Mortality Insurance?
Are your horses currently insured for mortality?
Yes
No
Horse Liability Insurance?
Do you currently have liability insurance for your horses?
Yes
No
Horse Mortality Coverage
Mortality Insurance Carrier Name
What is the name of the horse mortality insurance company?
Mortality Coverage Limits Upload
Please feel free to upload a copy of your horse mortality policy or other document that shows the coverage limits.
Drop files here or
Select files
Max. file size: 128 MB.
Horse Mortality Limits
Please enter the horses' names and mortality coverage limits below.
Horse Name
Morality Coverage Limit
Horse Liability Coverage
Liability Insurance Carrier Name
What is the name of the insurance company that provides the horse liability coverage?
Horse Liability Coverage Upload
Please feel free to upload a copy of your horse liability policy, if available.
Drop files here or
Select files
Max. file size: 128 MB.
Horse Liability Coverage Limits
Please select your horse liability policy's coverage limit.
$100,000
$300,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$5,000,000
$10,000,000
Other
Horse Liability Limit Coverage - Other
Please enter your coverage limit for horse liability insurance.
Documents and Comments
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, jewelry appraisals, etc...)
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, etc...)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 25.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
Consent
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree
Christine Marcialis
4076961333
https://www.pontellinsurance.com/
christine@pontellinsurance.com
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