Equine Risk Evaluation

Insured 1 - First Name*

What is your first name? *

Insured 1 - Last Name*

What is your last name? *

Insured 1 - Phone Number*

What is your preferred phone number? *

Email*

Please enter your email. *

Please enter the location address.*

Please enter your primary home address. *

Street Address Address Line 2 City State 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.

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

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

Max. file size: 128 MB.

Horse Liability Coverage Limits

Please select your horse liability policy's coverage limit.

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

Max. file size: 128 MB, Max. files: 25.

Please enter any additional remarks in the space below.

Consent*

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

Equine Ownership Details

Horse Mortality Coverage

Horse Liability Coverage

Documents and Comments

Agent Name

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Equine Risk Evaluation

Equine Ownership Details

Horse Mortality Coverage

Horse Liability Coverage

Documents and Comments

Agent Name

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter