Equine & Farm Sanctuary Insurance Application

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Section 1 - General Information

• Name of Organization: *
• Doing Business As (if applicable):
• Physical Address of Organization:
City:
State:
- Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands
Zip Code:
• Mailing Address of Organization: *
Mailing City: *
Mailing State: *
- Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands
Mailing Zip Code: *
Contact Name: *
Title
• Phone Number *
• Email *
• Fax
• Website

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Section 2 - Organization

• Business Type: *
  Individual Partnership Corporation LLC Other
• If "OTHER" for organization, please list:
• Entity Type: *
  For Profit Non-Profit
• 501c Status:
• Do you have any subsidiary organization?
  YES NO
• Type of Organization:
  Foster Based Rescue Exotic Animal or Marine Sanctuary Wildlife Rescue/Rehab Shelter/Humane Society/SPCA Equine/Farm Rescue TNR
• Federal Employer Identification Number (FEIN):
• Annual Revenues:
• Date Organization Established:
• Requested Effective Date:
• *Do you currently have insurance? *
  YES NO

*If "YES", please provide "Loss Run" report from your current insurance company.

• Current Insurance Company Name:
• Limits of Coverage Requested *
  $500,000 / $1M $1M / $1M $1M / $2M $1M / $3M

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Section 3 - Management Experience

• Number of years in operation:
• Manager's years of animal welfare experience:
• Executive Director's years of animal welfare experience:
• If Manager or Executive Director has less than 3 years of animal welfare experience, describe the executive director's and/or managers prior animal welfare experience:

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Section 4 - Coverage

• What insurance coverages are you interested in?
  General Liability Volunteer Accidental Medical Professional Liability Directors & Officers (D&O) Workers Compensation Property Business Automobile Hired & Non-Owned Auto
• Limits of Liability Request $:

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Section 5 - General Liability

• # of Employees *
• # of Volunteers *
• # of Foster Homes *
• Are all volunteers/employees over 18 years old? *
  YES NO

(If "NO" to volunteers over 18, complete the Abuse Supplement - section 12)

• Do you perform euthanasia? *
  YES NO
• If "YES" to performing euthanasia, are all drugs stored securely and tracked?
  YES NO
• Does the organization require background checks and/or conduct drug testing employees and/or volunteers? *
  YES NO

What is the experience requirements for:

• Employees
• Volunteers
• Are volunteers closely supervised? *
  YES NO
• Are Agreements with Hold Harmless Waivers signed by: *
  Fosters Volunteers
• How does the organization evaluate and train fosters and volunteers? *
• How does the organization train employees? *
• Does the organization have separate job descriptions for employees and volunteers? *
  YES NO
• Are the fosters/volunteers trained in Animal Body Language? *
  YES NO
• Is Zoonotic disease information provided to fosters/volunteers? *
  YES NO
• Are you compliant with all state regulations & protocols regarding rabies? *
  YES NO
• Description of your operations: *
• Are you licensed by the USDA? *
  YES NO
• If "YES", please include a copy of your license.
• Are you accredited or certified by GFAS? *
  YES NO
• Are fences inspected and repaired regularly? *
  YES NO
• Is there 24-hour supervision of the facility? *
  YES NO
• Are emergency numbers clearly posted? *
  YES NO
• Are safety and barn rules posted at the facility? *
  YES NO
• Are no smoking signs clearly posted? *
  YES NO
• Do you have a first aid station? *
  YES NO
• Do any Associations, Pony Clubs, 4-H, Girl/Boy Scouts, etc. use your facility? *
  YES NO
• If "YES", please explain:
• Are hold harmless agreements in place and kept in a file? *
  YES NO
• *If "YES", please enclose a copy of hold harmless agreements*
• Do you lease horses to or from others? *
  YES NO
• If "YES", please provide details & copy of the lease agreement:
• Copy of lease agreement:

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Animals

• How many animals on average are in the possession of the organization at any given time? *
• How does this organization assess the health of animals in its care? *
• Does the organization accept or adopt aggressive animals? *
  YES NO
• Does the organization have procedures in place for handling animals known to bite? *
  YES NO
• Does the organization label the paddock of aggressive or fearful animals? *
  YES NO
• Does this organization have a formal policy for reporting bites and injuries? *
  YES NO
• Are all animals vaccinated? *
  YES NO
• Spayed/Neutered? *
  YES NO
• Are all animals on lead when moving them through the facilities? *
  YES NO

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Adoption

• How are adoptive families screened? *
• Are potential adoptors/owners allowed to test ride? *
  YES NO
• If "YES" to allowing to ride, is a Hold Harmless Agreement signed? *
  YES NO
• If "YES" to allowing to ride, is proper footwear and headgear worn?
  YES NO
• Are all interactions with potential adoptive families closely supervised in secure areas? *
  YES NO
• Does the adoption contract contain a hold harmless waiver? *
  YES NO
• Does this organization participate in off-site adoption events? *
  YES NO
• If "YES", how many per year?
• Are handlers trained to ensure the safety of the pets and prospective adopters at these events? *
  YES NO

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Events

• Does this organization host or sponsor any events or activities? *
  YES NO
• If "YES" to above, please attach flyer and describe the events:
• Attach flyer here:

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Other Activities

• Is the organization involved in any of the following activities?
  Dude Ranch Pony Rides Public Horse Rental Amusements involving animal (including parades) Hay/Sleigh Rides Therapeutic Riding

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Other Exposures

• Does this organization offer day camps/activities for children? *
  YES NO

(If "YES" to offering day camps/activities for children, complete the Abuse Supplement - section 12)

• Describe activities that are offered for the children:
• What is the average daily attendance?
• How many days is the camp?
• What is the ratio of staff/volunteers to children (in format of "____ to ____")?
• Is there a pool or pond on site?
  YES NO
• If "YES", is it fenced?
  YES NO
• Is there a locked gate?
  YES NO

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Training

• Does this organization offer training to the public? *
  YES NO
• Are animals required to be vaccinated and on-leash for training sessions?
  YES NO
• Does the animal owner sign an agreement?
  YES NO
• Does the agreement have a hold harmless waiver?
  YES NO

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Animal Control/Humane Officers

• Do you employ any animal control officers? *
  YES NO
• How many?
• Are officers self-insured?
  YES NO
• Are they authorized to carry firearms?
  YES NO
• Are they state licensed?
  YES NO
• Do they have seizure authority?
  YES NO
• Is a warrant obtained and police present when seizing an animal?
  YES NO

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Director & Officers Liability (If "Non Applicable", please move to next section)

This is a claims made policy.

• Retroactive date requested:
• Total Assets $: *

(Copy of prior uninterrupted insurance is required to honor a retroactive date prior to effective date)

• Limits of coverage requested:
  $250000 $500000 $1000000

Retention is $1,000

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Exposures

• Current insurance company: *
• Do you currently have insurance in place? *
  YES NO

*If "YES", please provide "Loss Run" report from current company and a copy of the current Directors & Officers Liability Policy declaration page*

• Loss Run Report
• Directors & Officers Liability Policy Declaration Page

Financial Information:

• Annual Revenue (prior year) $: *
• Annual Expenses (prior year) $: *
• Total Assets (prior year) $: *
• Total Liabilities (prior year) $: *

If your organization is new, please provide estimated financial data above.

• Are financial statements prepared annually by an outside accountant or CPA? *
  YES NO
• Are finances audited annually by an outside accountant or CPA? *
  YES NO

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Financial Controls

• Does any one person have the authority to make financial decisions impacting greater than 5% of your organization's annual budget without approval from the governing board? *
  YES NO
• Do any of your Directors, Officers, or Trustees have a business relationship which could create a conflict of interest? *
  YES NO
• If "YES", what are the conflicts and how are they managed?
• Has the organization or any person proposed for coverage herein been the subject of, or involved in litigation, an administrative proceeding, disciplinary action, criminal action, revocation, or suspension in the past (5) years? *
  YES NO
• If "YES", please explain why:

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Claims/Incidents

• Are there any claims or lawsuits against your organization (including employees, independent contractors, or volunteers) of which you or any other director, officer, or administrator are aware that are not included in the claim information/loss runs provi *
  YES NO
• If "YES", have all such pending claims been reported to the prior carrier?
  YES NO
• If any pending claims have not been reported to the prior carrier, please explain:
• Are there any incidents or circumstances known to your organization (you or to any other director, officer or administrator), that have not been reported to the prior carrier, and for which there is reason to believe that such incident or circumstance may *
  YES NO
• If "YES", please explain as to why:
• Has your organization had similar coverage declined, cancelled, or non-renewed during the prior five years? *
  YES NO

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Hired & Non-Owned Auto Liability (If "Non Applicable", please move to next section)

• Number of employees and volunteers who use their own vehicle in the course of business: *
• Describe how employee and volunteer vehicles are used in your organization: *
• Prior to hire, do you check motor vehicle records (MVR's)? *
  YES NO
• Prior to hire, do you obtain copy of driver's license? *
  YES NO
• Do you collect evidence of personal auto insurance annually? *
  YES NO
• If "YES", what limits of liability coverage do you require?
• Do you prohibit texting and use of cell phones while driving? *
  YES NO
• What driver selection criteria does your organization use to allow staff/volunteers drive for you? *

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Section 12 - Abuse and Youth Volunteer Supplemental

Prior to hire, does the organization do the following?

Obtain a complete employment/volunteer application?

• Employees
  YES NO
• Volunteers
  YES NO

Check personal or business references?

• Employees
  YES NO
• Volunteers
  YES NO

Check National Sex Offender Public Registry?

• Employees
  YES NO
• Volunteers
  YES NO

Conduct criminal background checks?

• Employees
  YES NO
• Volunteers
  YES NO

Have a written sexual abuse policy?

• Employees
  YES NO
• Volunteers
  YES NO

Do staff and volunteers sign-off on abuse policy?

• Employees
  YES NO
• Volunteers
  YES NO

Youth Volunteers

• Do the youth volunteers work directly with the animals?:
  YES NO
• Are the youth volunteers supervised by an adult at all times?:
  YES NO
• Is there always more than one person with youth at all times?
  YES NO
• Do parents sign a consent with a hold harmless waiver for the youth volunteers?:
  YES NO

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Warranty

The application for this policy is incorporated and warranted as part of this policy. This insurance policy is being issued in reliance on the accuracy, truthfulness, and completeness of the application.

Any inaccuracy, falsity, or omission, regardless of the nature, shall entitle us to rescind the policy.

I declare that the information provided in this application is accurate, true, and complete and that each location currently complies and will comply with the rules and regulations set by state and federal law.

I understand that if I willfully do not comply with these rules and regulations that coverage is null and void and any claims may be denied and premium returned.

If the information supplied on the application changes between the date of the application and the effective date of the insurance, I will immediately notify AWOIP of any changes.

In the event of any changes AWOIP may withdraw or modify any outstanding quotations and/or agreement to bind the coverage.

I must notify AWOIP of any changes in operation of this business during the policy period, and failure to do so may result in cancellation of the coverage or denial of a claim.

I hereby authorize AWOIP to obtain information necessary for the evaluation in determining acceptability, including, but not limited to, physical inspections and inquiries with the state/county regulators.

This application does not guarantee approval for insurance. AWOIP reserves the right to decline coverage.

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This application requires the following attachments:

• Copy of volunteer agreement and application
• Copy of foster agreement and application
• Copy of adoption agreement and application
• Copy of any contracts
• 3 years of currently valued loss runs from existing and previous insurance companies (if no prior insurance, a statement of "No Known Losses")
• Producer Name:
• Agency:
• Agency Address:
• Email Address:

By checking the box below, you are agreeing to the Terms & Conditions, including, but not limited to:

The policy will be issued in reliance on the accuracy, truthfulness, and completeness of the application. Any inaccuracy, falsity, or omission, regardless of the nature, shall entitle us to rescind the policy.

A copy of this application will be incorporated and attached to the Policy.

Terms & Conditions

• * I have read and agree *
  I have read and agree
• Type Name and Title as signature that you agree to the above statement *
• Print Name *
• Date *

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Cyber Suite Liability - Opt-Out

If you do not wish to have Cyber Suite Liability Insurance extended to cover your business, you will need to complete the opt-out form and forward to your agent.

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I decline to have the Cyber Suite Liability Insurance extended to cover my business.

I understand that I am responsible for the cost of an actual or suspected violation of a privacy regulation due to a security breach.

This includes results in an unauthorized release of protected personal information which is any private, non-public information of any kind in our care, custody or control.

I understand and agree that the Cyber Suite Liability Insurance will not be available to me to recover expenses due to a security breach.

I hereby certify that I am authorized to sign on behalf of my company, partnership, etc.

• Business Name:
• Address:
• City:
• State:
  - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands
• Zip:
• E-Signature:
• Date:
• Print Name:
• Title:

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Employment Practices Liability - Opt-Out

If you do not wish to have the Employment Practices Liability Insurance extended to cover your business, you will need to complete the opt-out form and forward to your agent.

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I decline to have the Employee Liability Insurance extended to cover my business.

I hereby certify that I am authorized to sign on behalf of my company, partnership, etc.

• Company Name
• Address:
• City:
• State:
  - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands
• Zip:
• E-Signature:
• Print Name:
• Date:
• Title:

Submit