Fillable Equine Care, Custody and Control Application Coverage applies (Abram Interstate Insurance)

Fill Online, Printable, Fillable, Blank Equine Care, Custody and Control Application Coverage applies (Abram Interstate Insurance) Form

Use Fill to complete blank online ABRAM INTERSTATE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Equine Care, Custody and Control Application Coverage applies (Abram Interstate Insurance)

On average this form takes 61 minutes to complete

The Equine Care, Custody and Control Application Coverage applies (Abram Interstate Insurance) form is 4 pages long and contains:

  • 0 signatures
  • 22 check-boxes
  • 232 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Abram Interstate Insurance forms online.

BROWSE ABRAM INTERSTATE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Agency Phone # () -
Producer
New Business
Renewal of #
Agency Bill
A
Semi-
A
Q 10 payments Direct Bill to Applican
t
A
Monthly Mulitiple
() -
1-
2- Instruction
3-
4-
5-
6-
7-
8-
9-
Producer No
If not - details
Training
Lessee of stable -
provide copy of lease agreement with application. Lessee or Property owner responsible for fence repair?
Operations by you or your employees consist of: Boarding
Stable Owner Other
Have you ever been cancelled or non-renewed?
Are you in compliance with your states equine law?
How long have you been in business?
Business operated by
Please provide a copy of your boarding and release agreements.
Yes No
Zip
WWW.
Agency installments require premium to be $1,000 or more plus there are installment
Applicant - Name and address ( include County and Zip Code)
Applicant is
Direct Bill installment plans have fees.
Other
Corporation
City Co
Insured's Phone Number
St
Equine Care, Custody and Control Application
(Note: This is not a Binder. Incomplete or unsigned applications will be returned for completion.)
Company Use Only
Coverage applies only to
Non-Owned Horses
Customer No.
Agency's Name and address (Include Zip Code)
City
Breed of Horses
Breeding
Manager
Issue
Effective Date
to
Partnership LLC
Transaction
Owner/Operator
Quote
Absentee Owner
Quote Desired By
ZipSt
Maximium # of non-owned horses in your care?
Details
Are there any times that the number of horses will increase above maximum?
Average # of non-owned horses in your care?
Minimum # of non-owned horses in your care
Other
DetailsNo Yes
Limits of Liability
No Yes
Do you carry liability coverage? No Yes Name of carrier
Use of animals
CCC - Feb. 2004 Page 1 of 4
Submit Form
RESET
Submit Form
RESET
10-
11-
12- Is there 24 hour security and supervision of stables?
13-
14-
15- No
16-
17-
18-
19-
20-
21-
22-
Yes
23-
If yes, were they installed by manufacturer?
24-
25-
Stable #1
Stable #2
Fire Protection Class?
Construction # of Stalls? Sprinklered? Lightning Rods? Fire Ext?
Central Station
Alarm?
If building 20 years or older have the
roof, electrial and plumbing been updated
or inspected by a licensed contractor?
Provide details
Smoke/Fire
Alarms?
Name of Responding Fire Station
Stable #4
Stable #3
Yes No
NoYesHydrants within 1,000 feet of structures
Describe
Distance between FD and Property
What type of fencing is used in runs, pastures and paddocks?
Any wire fencing used for confinement? Yes
Details
Are shelters provided in runs or pastures? Yes No Describe
Where are horses kept in the evening? Stable, pasture etc.
Total value of all horsesAverage value of horses in your care Per Horse
Are stallions kept separated from mares? Yes No
Are health statements required before accepting non-owned horses?
Are you for hire to transport non-owned horses? No Yes
Note: Commerical hauling of non-owned horses other then those
you train/breed are excluded.
Yes No
What are the emergency procedures for an ill horse if owner is not available?
Do you transport horses that are boarded at your facility ?
How ofter are trailer or van floor boards checked?
Maximum Radius?
Maxiumum value of horses in your care Per Horse Total value of all horses
Total value of all horses
Who was the electician?
Equine Care, Custody and Control Application
Minimum value of horses in your care Per Horse
No
Yes No
Yes Annual Receipts.
Do your employees (if any) have instructions, in writing, on their responsibilities in case of stable fire?
No
Maximum number of horses per trip?
If yes, please attach instructions
Do you have therapeutic pools / aqua treads for horses? Yes No
Yes No
Are fire extinguishers carried on truck or van? Yes No Do at least two people go on each trip?
Name/Address of regular Veterinarian
Maximium number of trips per year? Average Radius?
CCC - Feb. 2004 Page 2 of 4
Submit Form
RESET
26-
Kentucky:
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for th epurpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also
be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such
Any person who knowingly and with intent to defraud any insurance company or other person files a satement of claim
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime.
A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
All Insurance applications and claim forms except auto:
Any person who knowingly and with intent to injure, or defraud any insurer files any application or claim containing any
false, incomplete or misleading information shall, upon conviction, be subject to immprisonment for up to 1 year for a
misdemeanor conviction or up to 10 years for a felony conviction and payment of a fine of up to $5,000,000.
Agents Signature:
Minnesota:
Michigan:
New York:
Comments
Applicant's Signature: Date
The above statements given are true and accurate. This includes the limits of insurance and loss history as shown. I have not
willfull
y
concealed or misre
p
resented an
y
material, fact or circumstance concernin
g
this a
pp
lication
.
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any
false, incomplete or misleading informatin shall, upon conviction, be subject to imprisonment for up to 7 years and
payment of a fine of up to $15,000.
Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim containin
g
any false, incomplete or misleading information is guilty of a felony.
INSURANCE FRAUD WARNING - APPLICANT TO INITIAL ALL APPLICABLE STATES
Delaware:
Date
Pennsylvania:
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma:
Ohio:
Equine Care, Custody and Control Application
Describe any losses or potential claims in the past three years and include deaths of any animal(s) in your custody, even if a claim was
not presented:
CCC - Feb. 2004 Page 3 of 4
Submit Form
RESET
minimum
p
remium for first 1-20 horses
12
(( + ( = )) =
X
(( + ( = )) =
X
(( + ( = )) =
X
* SC X
3
$330 minimum premium for the first 1-20 horses
Options
1
2
*Annual Premium
-
Manual
Co Tier
PKG - IRPM
Co Tier
*Annual Premium
-
Manual
Additional charge for
additional horses
1+2 Company Use
Final Premium
CCC - IRPM
PKG - IRPM
1+2
9
1+2
*
Annual premiums are subject to state charges (SC) and individual risk premium modifications (IRPM).
additional premium for each horse over 20.
*
Annual Premium
-
Manual
#of horses
over 20
Charge for
each add'l
X
First 20
horses
#of horses
over 20
Charge for
each add'l
Additional charge for
additional horses
Limit - $5,000 per horse - $25,000 maximum loss per policy year.
$12 additional premium for each horse over 20
$14 additional premium for each horse over 20
Limit - $10,000 per horse - $100,000 maximum loss per policy year.
$385 minimum premium for the first 1-20 horses
$440 minimum premium for the first 1-20 horses
$
825 minimum premium for the first 1-20 horses
Limits other then those designated above - refer to company for rating.
$
1,650 minimum premium for the first 1-20 horses
$
24 additional premium for each horse over 20
Limit -
$
200,000 per horse -
$
500,000 maximum loss per policy year.
$
28 additional premium for each horse over 20
Limit - per horse
X
6
7
8
Option Option Option
4
5
CCC - IRPM
Limit -
$
25,000 per horse -
$
250,000 maximum loss per policy year.
$
22 additional premium for each horse over 20
Limit -
$
50,000 per horse -
$
250,000 maximum loss per policy year.
$
990 minimum premium for the first 1-20 horses
$
22 additional premium for each horse over 20
Maximum loss per policy year.
First 20
horses
#of horses
over 20
Charge for
each add'l
Additional charge for
additional horses
X
$11 additional premium for each horse over 20
$275 minimum premium for the first 1-20 horses $9 additional premium for each horse over 20
Limit - $10,000 per horse - $50,000 maximum loss per policy year.
Limit -
$
5,000 per horse -
$
50,000 maximum loss per policy year.
Limit -
$
100,000 per horse -
$
300,000 maximum loss per policy year.
$
550 minimum premium for the first 1-20 horses
First 20
horses
* SC X
Company Use
CCC - IRPM
PKG - IRPM
Co Tier
Equine Care, Custody and Control Application
Average number of horses on premise at one time.
Final Premium
Final Premium
* SC X
Company Use
CCC - Feb. 2004 Page 4 of 4
Submit Form
RESET
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Equine Care, Custody and Control Application Coverage applies (Abram Interstate Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document