LIABILITY QUESTIONNAIRE

Named Insured: Policy Number:

“You” and “your” refer to the Named Insured, all resident relatives and any Additional Insured’s on the policy that include CPL.

ALL

Yes No

1. Do you own or care for any dogs? If yes, list the # and breed:

Have dogs owned by you/in your care caused damage to property/persons?

If yes, give date, type of damage and item/person damaged:

2. Are there any horses owned by, used by, or in your care? If yes, give number and explain use:

Do you receive compensation for activities related to the horses?

If yes, explain:

3. Is there any trampoline on the premises?

4. Is there a swimming pool or pond on your premises?

If yes, is it fenced? Any diving board or slide? Depth?

5. Do you own any recreational vehicles (snowmobiles, ATV’s, etc.)?

If yes, list type, serial number, and horsepower:

Are recreational vehicles used off premises?

Do you own a 3-wheel all terrain vehicle?

If yes, who operates this vehicle:

6. Do you own any other residences?

If yes, where are they located:

Do you want liability coverage for this location?

7. Do you rent any property or residence to others?

If yes, list locations:

8. Do you hire someone to clean your house on a regular basis?

9. Is there any person with an ownership in your real/personal property?

If yes, list names:

10. Do you have any hobbies for which you receive compensation?

If yes, list hobbies and gross receipts:

11. Do you babysit for compensation?

If yes, how many children are involved:

12. Any other business exposures on the insured premises?

If yes, explain:

13. Do you own any watercraft?

If yes, list type and horsepower:

14. Have you had insurance cancelled or non-renewed in the last 5 years?

If yes, please explain

15. Have you had any lapse in insurance coverage in the last 5 years?

16. Are any dwellings or buildings vacant?

17. Is any of the property currently for sale or in foreclosure?

18. Does “any” insured have any other liability insurance in force?

19. Any porch, deck or steps in poor condition or without a railing?

20. Has the property been inspected?

When? By Whom?

21. List ALL liability claims in the last five years (date, description, amount paid, reserve open)

(please attach a loss run, or provide the claims information below)

ADDITIONAL FOR FARM Yes No

1. If you are farming, do you share ownership with any others?

If yes, list names and addresses:

Do you want liability coverage for those individuals?

If yes, do you want liability for activities related to the premises only or

liability for personal activities and premises liability? PL OR Premises Only

Do they have any other liability insurance?

2. Do you sell any products, other than farm products, from your residence?

If yes, list products and gross receipts:

3. Do you have any operations or activities that are related to the farm

operations for which you receive compensation?

4. Do you retail any products to the consumer?

If yes, list where, how often, and gross receipts:

5. Do you do any custom farming?

If yes, explain operation and list gross receipts:

6. Do you hire any employees to assist with custom farming?

7. Do you rent any farm buildings?

If yes, do you want liability coverage for fire, smoke, and explosion?

8. Are all farm locations connected?

9. Do you have to travel on the roads to get from one location to another?

10. Have you ever had a claim that was caused by livestock, including horses,

that had escaped from your premises?

If yes, explain:

11. Are all fences “legal” and in good condition?

12. Do you have employees?

If yes, how many:

13. Do you have any relatives who are employees?

If yes, list their names and addresses:

14. Do you own a bull?

Do you rent the bull to others?

15. List all locations owned, rented, or used (include those used for farming):

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LIABILITY QUESTIONNAIRE

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