lkalmanson - Carriage Liability

AGENCY:LESTER KALMANSON AGENCY, INC. &/OR MITCHEL KALMANSON

235 S. MAITLAND AVE., SUITE 201
P.O. BOX 940008 – 0008
MAITLAND, FL / U.S.A.
PH. 407-645-5000 / FAX: 407-645-2810
WWW.LKALMANSON.COM

IMPORTANT: "THIS IS NOT A BINDER"

INCOMPLETE & UNSIGNED APPLICATIONS ARE NOT ACCEPTABLE

PROPOSED EFFECTIVE DATE

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TERM:

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NAME OF INSURED

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DOING BUSINESS AS

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MAILING ADDRESS

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CITY

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STATE

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ZIP

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PHONE

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FAX

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CELL:

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EMAIL

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select

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IF OTHER

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PHYSICAL LOCATION(S) WHERE HORSE (S) / CARRIAGE(S) WILL BE KEPT: (IE. DESIGNATED PREMISES)

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YEARS IN BUSINESS

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REQUESTED LIMITS OF LIABILITY PER OCCURRENCE / AGGREGATE

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IF OTHER

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STATE LIMIT(S) REQUESTED

PROPOSED DEDUCTIBLE: $

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PER CLAIM (BI/PD)INCLUDING L.A.E.
(MINIMUM $2,500)

MAXIMUM NUMBER OF CARRIAGE(S) (UNITS) USED AT ANY ONE TIME

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MAXIMUM NUMBER OF (DRAFT) HORSE(S) / MULE(S) OWNED &/OR NON OWNED IN CARE, CUSTODY &/OR CONTROL USED IN YOUR COMMERCIAL CARRIAGE / WAGON OPERATION(S)

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INDICATE TOTAL NUMBER OF CARRIAGE(S)/(UNITS) OWNED

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A) STATE IF YOU HAVE ANY LEASED & / OR NON-OWNED CARRIAGE/UNIT(S)

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MAXIMUM NUMBER OF HORSES/MULES PER CARRIAGE/WAGON USED

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DESCRIBE EXACT USAGE OF ALL CARRIAGE(S) / UNIT(S)

WEDDINGS

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TOURS

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PARADES

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SPECIAL EVENTS

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OTHER

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OTHER

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ATTACH COPY(S) OF ANY AND ALL BROCHURES, PAMPHLETS, ALONG WITH
ANY SAFTEY MANUALS, RECORDS, ETC. USED IN YOUR OPERATION(S)

PRIOR CARRIER INFORMATION ( LAST THREE YEARS )

COMPANY - POLICY # - POLICY PERIOD - LIMITS - PREMIUM(S) - DED'T

A)

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B)

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C)

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LIST SAFETY EQUIPMENT WITH WHICH YOUR VEHICLES IS / ARE EQUIPPED

HYDRAULIC BRAKES

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LIGHTS

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REFLECTORS

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SLOW MOVING VEHICLE EMBLEM (S)

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OTHER

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OTHER

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LOSSES IN THE PAST THREE YEARS

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DATE OF LOSS DESCRIPTION AMT PAID AMT RESERVED

A)

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B)

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C)

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HAS ANY PRIOR COVERAGE BEEN CANCELLED & / OR NON-RENEWED

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IF YES, EXPLAIN

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O P T I O N A L C O V E R A G E S

PREMISES LIABILITY OF STABLE(S) USED FOR THE BOARDING AND TRAINING OF OWNED HORSES ONLY USED IN CONJUNCTION WITH THE NAMED INSUREDS CARRIAGE OPERATION(S). (PROVIDE LIST OF ALL LOCATION(S) TO BE SCHEDULED AND INSURED)

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PREMISES LIABILITY OF STABLE(S) USED FOR THE BOARDING AND TRAINING OF OWNED HORSES ONLY USED IN CONJUNCTION WITH THE NAMED INSUREDS CARRIAGE OPERATION(S). (PROVIDE LIST OF ALL LOCATION(S) TO BE SCHEDULED AND INSURED)

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ADDITIONAL INSURED(S) TO BE INCLUDED:(PLEASE PROVIDE NAME, ADDRESS, PHONE, FAX, AND RELATIONSHIP)

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ADDITIONAL INSURED(S) TO BE INCLUDED:(PLEASE PROVIDE NAME, ADDRESS, PHONE, FAX, AND RELATIONSHIP)

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CERTIFICATE(S) OF INSURANCE REQUESTED

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IF YES, PLEASE PROVIDE NAME, ADDRESS, PHONE, FAX. ETC. OF CERT. HOLDER

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ARE INDEPENDENT CONTRACTORS USED

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IF YES, EXPLAIN (MAIL/FAX COPY OF FORMAL / WRITTEN AGREEMENT(S))

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ESTIMATED GROSS ANNUAL RECEIPT(S)

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MUST BE ANSWERED

SPECIFIC EXCLUSION / WARRANT:

IN CONSIDERATION OF THE PREMIUM CHARGED AT INCEPTION, IT IS HEREBY
UNDERSTOOD AND AGREED THAT COVERAGE AS PROVIDED HEREIN DOES NOT APPLY
TO ANY CLAIM ARISING FROM ANY BODILY INJURY AND / OR PROPERTY DAMAGE
TO ANY PERSON INCURRED WHILE MOUNTING, RIDING, ATTEMPTING TO RIDE OR
DISMOUNTING ANY (SADDLED) ANIMAL, RENTAL OR LEASING OF ANY ANIMAL(S)
TO OTHERS INCLUDING, BUT NOT LIMITED TO, TRAIL RIDES AND / OR ANY
RIDING INSTRUCTION(S) AND / OR RIDING ACADEMY (S), PERFORMED BY OR
ONBEHALF OF THE NAMED INSURED(S) AND/OR ITS EMPLOYEES AND/OR ANY OTHERS

SADDLE ANIMAL(S) INCLUDE, BUT ARE NOT LIMITED TO, HORSES, PONIES,DONKEYS/MULES, BOVINES, CAMELS, ELEPHANTS, OSTRICHES AND LLAMAS, ETC.

WARRANT: NO LIABILITY COVERAGE IS AFFORDED WHILE RIDING ANY (SADDLED) ANIMAL UNLESS THIS EXPOSURE IS SPECIFICALLY ENDORSED TO THE POLICY.

I HAVE READ THE ABOVE WARRANT AND ACCEPT THIS SPECIFIC EXCLUSION AND RESTRICTION(S) AS NOTED / STATED ABOVE BY INITIALING AS FOLLOWS.

INITIAL

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DATE

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REMARKS (IF ANY)

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THE APPLICANT DECLARES THAT THE ABOVE STATEMENTS AND REPRESENTATIONS
ARE TRUE AND CORRECT AND THAT NO FACTS HAVE BEEN SUPPRESSED OR
MIS-STATED. THE COMPLETION OF THIS APPLICATION DOES NOT BIND THE
COMPANY TO SELL NOR THE APPLICANT TO PURCHASE THIS INSURANCE.

INITIAL AND DATE TO ACCEPT TERMS AS STATED ABOVE (REQUIRED TO PROCESS)

INITIAL

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DATE

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AFTER SUBMITTING THE ONLINE APPLICATION,
DOWNLOAD, PRINT, & COMPLETE THE "CARRIAGE SIGNATURE" & "TERRORISM" FORMS
BOTH FORMS REQUIRE WET SIGNATURES AND MUST BE MAILED TO OUR OFFICE TO
PROCESS THE APPLICATION

***CONFIDENTIALITY NOTICE: This message and any attachments are for the sole use of the intended recipient(s) and may contain confidential and privileged information that is exempt from any public disclosure. Any unauthorized use, review, disclosure, or distribution is prohibited. If you have received this message in error, please contact the sender by phone or electronic mail, and destroy all copies of this message.***

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CARRIAGE (TEAM HORSE/MULE) LIABILITY APPLICATION

AGENCY:LESTER KALMANSON AGENCY, INC. &/OR MITCHEL KALMANSON

AFTER SUBMITTING THE ONLINE APPLICATION, DOWNLOAD, PRINT, & COMPLETE THE "CARRIAGE SIGNATURE" & "TERRORISM" FORMS BOTH FORMS REQUIRE WET SIGNATURES AND MUST BE MAILED TO OUR OFFICE TO PROCESS THE APPLICATION

AFTER SUBMITTING THE ONLINE APPLICATION,
DOWNLOAD, PRINT, & COMPLETE THE "CARRIAGE SIGNATURE" & "TERRORISM" FORMS
BOTH FORMS REQUIRE WET SIGNATURES AND MUST BE MAILED TO OUR OFFICE TO
PROCESS THE APPLICATION