Fillable KINSALE Hotel Motel Supplemental Application

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KINSALE Hotel Motel Supplemental Application

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The KINSALE Hotel Motel Supplemental Application form is 4 pages long and contains:

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  • 67 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
HOTEL/MOTEL SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1) DATE:
2) APPLICANT NAME:
3) MAILING ADDRESS:
4) STREET ADDRESS (If different):
5) CITY, STATE, ZIP CODE:
6) WEBSITE ADDRESS: www.
1) Years owned by the insured?
2) Revenue information:
Prior 12 months Next 12 Months
Total Revenue
Room Revenue
Food Revenue
Liquor Revenue
Other Revenue (describe)
3) Clientele: Family-oriented Destination Resort Business Travel Bed & Breakfast
4) Is there a restaurant and/or bar on the premises? Yes No
If yes, what are the business hours?
5) Are cooking facilities provided in rooms? Yes No
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
6) Are rooms accessible by interior or exterior hallways? Yes No
7) Any special events/wedding receptions held on premises? Yes No
If yes, how many events per year?
8) Building Information:
Building Square Footage: Number of Rooms:
Number of Buildings: Average Room Rate:
Year Built: Parking Square Footage:
Number of Elevators: Average Occupancy: %
Number of Stories:
9) Pool Information:
a) Number of Pools:
b) Are there diving board or slides? Yes No
c) Area around pool fully fenced with a self-locking gate? Yes No
d) Are depths clearly marked? Yes No
e) Are warning signs and rules posted in a visible area? Yes No
f) Has the pool been retrofitted with an anti-vortex drain cover? Yes No
10) Check if any of the following: Beaches or Lakes Bike Trails Clubhouses Playgrounds
Fitness Center Sporting Courts Spa/Sauna Casino
Other:
11) If building over 15 years old, when were the following updates performed? Heating
Electrical Plumbing Roof
12) Type of wiring: Copper Aluminum Pigtailed
13) What percentage of building is sprinklered?
14) Number of exits per floor?
15) Does building have a manual fire alarm? Yes No
16) Does building have a central station fire alarm? Yes No
17) Does building have emergency lighting? Yes No
Page 3 of 4
18) Are smoke detectors in each unit? Yes No
If yes, are they: Hard wired Battery Both
19) Are carbon dioxide detectors in each unit? Yes No
If yes, are they: Hard wired Battery Both
20) Is any portion of the building leased to others? Yes No
Explain including square footage:
21) Is the premises covered by security cameras? Yes No
22) Are there security guards on the property? Yes No
Are they employees? subcontractors? provided by a private security company?
Are they armed? or unarmed?
23) Does insured provide any type of shuttle service for guests? Yes No
If yes, please explain:
24) Is there a snow and ice removal contract in place by an insured contractor? Yes No
25) Any construction planned during the upcoming policy period? Yes No
If so, describe?
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
Page 4 of 4
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application for
insurance or statement 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 and shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 and subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts. The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may
arise prior to the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may
be modified or withdrawn based upon such changes at our sole discretion. Completion of this form does not bind coverage. Applicant’s acceptance of
the company’s quotation is required prior to binding coverage and policy issuance. All written statements and materials furnished to the company in
conjunction with this application are hereby incorporated by reference into this application and made a part of this application.
Applicant:
Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Hotel Motel Supplemental Application

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Completed 2 July 2020

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