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TSW MANAGEMENT SERVICES INC.
NON-CERTIFIED INSTRUCTORS LIABILITY APPLICATION/DECLARATION
FULL NAME: ___________________________________________
ADDRESS:
_______________________________________________
_______________________________________________
POSTAL CODE:__________________
PHONE NUMBER: HOME______________ BUSINESS____________
FAX NUMBER:
___________________ EMAIL: ____________________
EC Membership # ________________
Date of Birth: ______________
PROPERTY INFORMATION
1) Do you occupy farm property? Yes ( ) or No ( )
2) If yes, is this property owned or leased? _______________
Number of acres________
3) If leased: a) Type of Building Leased? _____________________________________
b) Square footage of premises ____________________________________
4) Do you carry farm / property insurance? Yes ( ) or No ( )
5) If yes, what is the policy #______________ and expiry date ____________________
6) Does this policy cover “all” your operations? Yes ( ) or No ( )
7) If no, what is not covered? ________________________________________________
________________________________________________
**Please note that this liability would act as EXCESS LIABILITY over and above your Farm
Insurance Policy.**
RIDING INSTRUCTION
1. Gross revenue over the last 12 months: $___________
2. Estimated gross revenue over the next 12 months:
3. Estimated number of students per week:
$___________
____________
4. Do these students attend horse shows? Yes ( ) or No ( )
5. If yes, how many shows per year? ___________________
6. Are you always in attendance at shows with students? Yes ( ) or No ( )
7. Do you teach clinics? Yes ( ) or No ( )
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8. If yes: a) how many per year? _______________________
b) do the clinic sites provide liability coverage for you? Yes ( ) or No ( )
9. Do you provide clinics for your students by other instructors? Yes ( ) or No ( )
10.
If yes: a) how many per year?________________________
b) do the instructors have their own liability coverage? Yes ( ) or No ( )
OWNERSHIP OF HORSES
1. Do you own horses? Yes ( ) or No ( )
2. If yes, how many are used for:
a) showing _______________
b) lessons ________________
c) breeding _______________
d) other __________________
Explain fully _______________________________
TOTAL _______________________
NON-OWNED HORSES
1. Do you board horses? Yes ( ) or No ( )
2. If yes: a) Does your farm insurance cover you for this or do you carry a separate
liability policy? Yes ( ) or No ( )
b) Maximum number of boarded horses: _______________
c) Minimum number of boarded horses: _______________
d) Highest value of any one boarded horse:
_______________
e) Average value of any one boarded horse:
_______________
3. Do you train, show or care for any horses owned by others? Yes ( ) or No ( )
3. If yes, estimate how many non-owned horses you:
Maximum
Minimum
a) Train
_________
__________
b) Show
_________
__________
c) Other
_________
__________ Explain fully:______________
Total
_________
__________
5. Highest value of non-owned horse in your care is _________________________.
6. Average value of non-owned horse in your care is _________________________.
7. Do you own a horse trailer? Yes ( ) or No ( )
8. If yes, do you transport horses for others? Yes ( ) or No ( ) Explain _________
________________________________________________________________
9. If yes,
a) How many horse trailers do you own / operate?_____________
b) Combined stall capacity of all trailers? ____________________
c) Estimated annual trailer miles per year____________________
d) Value of non-owned horse shipped by you: Highest _________
Average_________
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OTHER OPERATIONS
1. Do clients sign contractual agreements/waivers for your services? Yes ( ) or No()
If yes, please attach a copy.
2.
Do you judge any horse shows? Yes ( ) or No ( )
3.
If yes: a) how many horse shows do you judge per year?___________________
b) are you covered by the show’s liability policy? Yes ( ) or No ( )
4.
Do you provide any course designing? Yes ( ) or No ( )
5.
If yes: a) how many show days do you design for / year?___________________
b) are you covered by the show’s liability policy? Yes ( ) or No ( )
6.
Do you operate any Horse Shows? Yes ( ) or No ( )
7.
If yes: a) how many per year? __________________b) Do these shows carry their own liability? Yes ( ) or No ( )
DO YOU PROVIDE ANY TRAIL RIDES OR SLEIGH RIDES? Yes ( ) or No ( )
DO YOU RENT YOUR HORSES TO THE GENERAL PUBLIC? Yes ( ) of No ( )
HAYRIDES,
SLEIGH RIDES,
AND
TRAIL RIDING FOR THE
GENERAL PUBLIC IS EXCLUDED FROM THIS POLICY
PROPERTY COVERAGE
1.
What is the value of your personal tack? $_____________________
2.
Highest value of any one item? $______________________
3.
Description of item if over $1,500: _____________________________________
4.
Where is your tack normally kept?______________________________________
5.
Do you carry cash from your business operations? Yes ( ) or No ( )
6.
If yes, what is the maximum amount carried any one time? __________________
7.
Do you wish coverage for operations not declared on this application? Yes ( ) or No ( ).
Please explain fully:_________________________________________
CLAIMS HISTORY
Please provide full details of any claim in the 5 years:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
________
PRIOR INSURANCE COMPANY & POLICY NUMBER: ____________________
_
____________________________________________________________________
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DECLARATION BY APPLICANT
I (WE) UNDERSTAND THAT ANY MISSTATEMENT ON THIS APPLICATION SHALL BE
CONSIDERED A VIOLATION OF COVERAGE AFFORDED BY ANY POLICY ISSUED ON
THE BASIS OF THIS APPLICATION, AND ANY POLICY ISSUED SHALL BE
CONSIDERED NULL AND VOID.
DATED THIS ON _________ DAY OF ___________, 200___ AT
__________________,__________________, CANADA.
SIGNED BY _________________________
SIGNATURE__________________________
(please print)
REQUESTED EFFECTIVE DATE OF COVERAGE:_____________________________
BROKER:
B.F. LORENZETTI & ASSOCIATES (ONTARIO) INC.
1605-181 University Avenue
Toronto, ON
M5H 3M7
Tel: 1-800-668-5901
(416) 599-5530
Fax (416) 599-5458
PREMIUM CALCULATION
Base Premium:
Receipts for instruction up to $10,000 per year
$ 500.00
Receipts for instruction $10,001 - $25,000 per year
$ 600.00
Receipts for instruction $25,001 - $ 100,000 per year & over
$ 750.00
Tenant’s Legal Liability $ 1,000,000 ($ 1,000 deductible)
$
50.00
Add: Premises Liability at $250 per location Yes ____ No ____
$ 250.00___
Add: Tack Coverage Limit $______X 2 % Yes ___ No ____
$__________
(Minimum Premium $ 250.00)
Add: Inside Outside Hold-Up Coverage $ 2,000 Yes ___ No ____ $ 250.00____
($ 500 Deductible) Flat Fee of $ 250.00
Add: Stableman’s Liability: Care, Custody & Control of Non-Owned
Horses $ 100,000 subject to a limit of $ 10,000/ any one horse
($ 1,000 Deductible). Flat Fee of $ 200.00
$ 200.00____
Do you require this coverage? Yes _____ No _____
INCREASE COMPREHENSIVE LIABILITY LIMIT:

to $3 Million – plus $ 125

to $4 Million – plus $ 250

to $5 Million – plus $ 375
$___________
AGENCY FEE
$ 25.00
Sub Total:
$____________
Plus applicable Provincial sales tax
$____________
TOTAL PREMIUM ENCLOSED:
$____________
PLEASE FORWARD THE SIGNED APPLICATION ALONG WITH YOUR CHEQUE
PAYABLE TO “TSW MANAGEMENT SERVICES INC.”
***NOTE: COVERAGE IS SUBJECT TO RECEIPT OF CHEQUE AND APPROVED,
COMPLETED APPLICATION.
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