Fillable MOTEL PROGRAM SUPPLEMENTAL APPLICATION (RT Specialty)

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MOTEL PROGRAM SUPPLEMENTAL APPLICATION (RT Specialty)

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  • 26 check-boxes
  • 198 other fields

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File type: PDF

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
MOTEL PROGRAM SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Operation: Hotel Motel Tourist Courts/Cabins Resort Dude Ranch
Other (describe):
2. Number of rooms: Average room charge: Average occupancy rate: %
Room rental by the: Hour Day Week Month Other (describe):
3. Any area leased/rented to others? ........................................................................................................... Yes No
If yes, to whom?
Describe how leased area is used and square footage: Area: Sq. Ft.
4. Does applicant have a national affiliation? ............................................................................................. Yes No
If yes, with whom?
5. Recommended by local Chamber of Commerce or American Automobile Association (AAA)?...... Yes No
6. Building information/protection:
Number of stories: Construction:
Central station fire alarm Local fire alarm Emergency lighting Sprinklered
Standpipes and hose Guest rooms have operating smoke detectors
7. Number of:
Baseball parks
Racquetball courts
Spa/hot tubs
Basketball courts
Saunas
Tennis courts
Boat docks/slips
Shuffleboard courts
Volleyball courts
Playgrounds
Ski lifts/tows
Other:
GLS-APP-48s (12-13) Page 1 of 5
Submit Here
8. Annual gross sales for applicants’ and their concessionaires’ operations:
$ Room rental
$ Convenience store ................................................... Number of stores:
$ Food from restaurant ................................................ Number of restaurants or lounges:
$ Liquor from restaurant or lounge
$ Conferences and conventions .................................. Maximum occupancy for premises:
$ Health or swim club .................................................. Number of members:
$ Equipment rental (snowmobiles, boats, skis, etc.) ... Type of equipment:
$ Other (describe):
$ Total sales from above
9. Other operations/exposures:
a. Boats? .................................................................................................................................................. Yes No
If yes: Number of boats:
Type (sail, power, canoe, etc.):
b. Clubhouses including exercise room? ............................................................................................. Yes No
If yes: Square footage:
c. Fuel sales? ........................................................................................................................................... Yes No
If yes: Gallons sold per year:
d. Golf course? ........................................................................................................................................ Yes No
If yes: Gross sales:
e. Lakes? .................................................................................................................................................. Yes No
If yes: Number of acres:
f. Park? .................................................................................................................................................... Yes No
If yes: Number of acres:
g. Recreational equipment rental other than canoes and rowboats?................................................ Yes No
If yes: Describe:
h. Saddle animals? .................................................................................................................................. Yes No
If yes: Number of animals:
Describe type of animal:
i. Shooting ranges? ................................................................................................................................ Yes No
If yes: Number of ranges:
Type (archery/skeet/trap/etc.):
j. Swimming? .......................................................................................................................................... Yes No
(1) Are there indoor pools? .................................................................................................................. Yes No
If yes: Number of indoor pools:
(2) Are there outdoor pools? ................................................................................................................ Yes No
If yes: In-ground Above-ground Number of outdoor pools:
(3) Are there wading pools? ................................................................................................................. Yes No
If yes: Number of wading pools:
(4) Are there bathing beaches? ........................................................................................................... Yes No
If yes: Ocean beach Lake/river beach Number of beaches:
(5) Are there diving boards/slides/rafts/platforms? .............................................................................. Yes No
If yes: Number of diving boards/slides/rafts/platforms:
Board/platform height: Slide height:
GLS-APP-48s (12-13) Page 2 of 5
(6) Are swimming rules posted? .......................................................................................................... Yes No
(7) Are depths of pool markings clearly visible? .................................................................................. Yes No
(8) Are outdoor pools fenced with a self-latching gate or enclosed by the building structure with no
direct access to roadways or parking areas? .................................................................................
Yes No
(9) Is life-safety equipment available at pool side? .............................................................................. Yes No
(10) Is a certified lifeguard available when swimming is allowed? ........................................................ Yes No
(11) Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia
Graeme Baker Pool and Spa Safety Act? ......................................................................................
Yes No
k. Trails? ................................................................................................................................................... Yes No
If yes: Number of bike trail miles:
Number of horse trail miles:
Other (describe):
10.
Describe any additional recreational facilities or operations conducted on the premises:
11. Innkeepers Liability limit:
$1,000 Per Occurrence/$10,000 Aggregate $2,500 Per Occurrence/$25,000 Aggregate None
12. Security:
a. Are employees required to wear ID badges at all times? ..................................................................... Yes No
b. Do room doors have viewing devices (peep holes)? ............................................................................ Yes No
c. Do room doors have deadbolt locks and door chains? ......................................................................... Yes No
d. Are door keys or card keys for electronic locks? .................................................................................. Yes No
e. Do adjoining room doors have deadbolt locks? .................................................................................... Yes No
f. Do sliding glass doors have security bars or poles within door tracks? ............................................... Yes No
g. Are guest names and room numbers released to others? .................................................................... Yes No
h. Do rooms contain security instructions for guests? .............................................................................. Yes No
i. Does facility have CCTV for monitoring parking and entrances? ......................................................... Yes No
j. Are there security guards? .................................................................................................................... Yes No
If yes: Number of employed security guards: Armed: Unarmed:
Number of contracted security guards: Armed: Unarmed:
13. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
14. Does applicant have any other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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 conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable to Oregon.)
GLS-APP-48s (12-13) Page 3 of 5
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
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 sub-
ject 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 a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, and any person who, in connection with such application or claim, know-
ingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction,
GLS-APP-48s (12-13) Page 4 of 5
damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insur-
ance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to ex-
ceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure a routine inquiry may be made to obtain applicable information concerning
character general reputation personal characteristics and mode of living. Upon written request additional information
as to the nature and scope of the report if one is made will be provided.
GLS-APP-48s (12-13) Page 5 of 5
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MOTEL PROGRAM SUPPLEMENTAL APPLICATION (RT Specialty)

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Completed 13 December 2020

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