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Agent Code:________
Named Insured:
DBA:
Phone Number:_________________________ Web Address:
Other lnsured(s):
Mailing Address:
Street City County State Zip Code
Effective Date Desired: Expiration Date:
(1 year term)
*PRIOR INSURANCE CARRIER AND LOSS HISTORY FOR THE PAST THREE YEARS
Year
Carrier/Policy Number
Premium
Coverage
Losses
Amount
Description of Losses, Date of Loss, Preventative Measures
(Use separate sheet if necessary)
*A credit may be available to the applicant if a copy of their prior carriers declarations page is attached to this application.
Has insurance been cancelled, refused or non-renewed by any company during the past three years? No Yes
- If yes, give name of company, date and reason. _______________________________________________________
Individual Partnership Corporation Joint Venture Other____________________________________________
Years in Operation: Years of Experience: How long has applicant owned the property?
Mortgagee/Loss Payee: Loan #
Street City County State Zip Code
Risk location(s) 1.
2.
3.
Street City County State Zip Code
COVERAGES
Property - Deductible Options: $1,000 $2,500 $5,000 $10,000 $25,000
Loc.
#
Bldg.
#
Limit of Insurance on building
Supplemental Heat
Surcharge
Occupancy or use
of building
Contents Limit
Optional Property Coverages
Business Income Limit $____________________
$25,000 Equipment Breakdown
Scheduled Contents (Attach listing or appraisal as required) Limit $______________
Property Coverage Extension Endorsement (Special Form)
Liability
Limit Requested: $ Occurrence/ $______________ Aggregate (Other Liability limits will be based upon those selected)
Total number of Rental Rooms___________________
Note: Personal Liability coverage is included upon purchase of CGL and only applies if owner resides on premises year round.
Optional Liability Coverages - Personal Injury Host Liquor Liability Restaurant Liability Gross Receipts $__________
Medical Payments $1,000 $2,500 $5,000 $10,000
SPECIALTY APPLICATION
Bed & Breakfast/Vacation Rental/Owner Event Venue Application
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UNDERWRITING INFORMATION
Exposures
Property (Complete for all covered buildings)
Loc. #
Bldg.
#
# of
Stories
Square
Footage
Construction Type
(Frame, Masonry, Stucco, Log, etc.)
Prot.
Class
Spkl.
Y/N
# of
Rental Units
Year
Built
Update Years:
Roof, Electric, Plumbing, & Heating
Neighborhood: Residential Mfg/Industrial Retail/Commercial
Type: Rural Coastal (Distance )* Other:
*I hereby acknowledge that the “WINDSTORM/HAIL COVERAGE GUIDELINES” have been explained to me and I
understand the limitations &/or exclusions that may apply to my coverage.
Yes No, Applicants Initials
Is your operation within 50 miles of the Gulf of Mexico or Atlantic Ocean?
Yes No
Condition: Stable Improving Deteriorating
Do you have any active Knob & Tube &/or Aluminum wiring in your facility? Yes No
Do you have a fuse box instead of a breaker box anywhere in your facility?
Yes No
Are you currently doing renovations &/or repairs to your facility? Yes No
Are you planning any renovations &/or repairs to your facility?
Yes* No
* If Yes, the contractor performing the work must carry a minimum of $1 million liability coverage, you must also provide a description of
the work being done.___________________________________________________________________________________________
Explain all Yes answers:________________________________________________________________________________________
___________________________________________________________________________________________________________
Is dwelling on a slope? Yes No Degree of slope? ________If over 30° angle risk is unacceptable.
Premises occupied by: Owner Innkeeper/Manager* Other:
* (Indicate years of Experience of the Innkeeper/Manager if not the owner__________)
Does the property owner reside on the premises full time?
Yes No, If No, Explain _______________________________________
Is the risk operational year round? Yes No, Explain if No
Does an owner/manager occupy the habitational buildings overnight where guests are present? Yes No
If No to above, (√) applicable life safety measures below that are in place:
Sprinklers in building:
Smoke alarms hardwired to fire department either directly or via a central station with under a 5 minute response time to premise:
Smoke alarms hardwired to the overnight area of the innkeeper/manager either directly or via a central station:
Smoke alarms hardwired to an outside siren audible by the innkeeper / manager:
Direct means of egress from each 1st floor bedroom via a window or door:
Direct means of egress from each 2nd floor bedroom via each window to a balcony or fire escape:
Is there a second separate (i.e. second stair way) means of egress for 3rd or 4th floor guestrooms? Yes No
Name of Responding Fire Department: Distance from Fire Department:
Distance from Hydrant:
What is the total revenue earned from rentals? $_____________ What is your average nightly rental charge? $______________
Do you have any antiques, heirlooms or fine arts? Yes No, If Yes, is any one item valued over $15,000? Yes No
Does each guest unit have a door lock, which may be locked from the outside? Yes No Do all windows have locks? Yes No
Do you maintain a restaurant facility? Yes No, If yes, gross receipts $
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Indicate the following cooking exposures that apply:
Electric
Gas
Under hood
Not Under
hood
Fuel Power
Shut-Off
Surface
Protection
Yes
No
Yes
No
Grill
Deep Fryer
Broiler
Range w/ Oven
Oven
Steam Table
Coffee Maker
Toaster
Infrared Oven
Other (describe)
Is gas safety shut off marked? Yes No None Exists Is gas safety shutoff known by employees? Yes No
Protection Devices: Sprinklered Local Security Fire Alarm Central Station Security Fire Alarm Other:
How often is equipment inspected and maintained?
Describe maintenance program:
Number of fireplaces wood burning stoves Are any located in the rental units? Yes No
Are guests permitted to: operate fireplaces or wood burning stoves? Yes No
Are guests allowed to smoke in any building on premises?
Yes No
Do all rental units contain smoke detectors?
Yes No
Do any rental units have cooking facilities?
Yes No
Do any rental units utilize space heaters? Yes No
Are any mortgage payments (building and contents) overdue by three months or more?
Yes No
Are there any tax liens against the property or business?
Yes No
Are any taxes unpaid or overdue for 1 year or more?
Yes No
Are there any current violations of fire safety, health building or construction codes at this location?
Yes No
Has anyone with a financial interest in this property been convicted of arson,
fraud, or other crime related to loss on property owned now or during the last five years?
Yes No
Is the mortgagee other than a federal or state chartered lending Institution?
Yes No
Explain all Yes answers ________________________________________________________________________________________
General Liability
Are your facilities licensed to operate as a Bed and Breakfast? Yes No
Have your facilities been inspected in the past 12 months? Yes No, by whom?
Any livestock on the premises? Yes No, describe
Any pets on the premises? Yes No, describe
Do you conduct any other businesses on the insured premises? Yes No If yes, what type of business?_________________
Is there any foot traffic for any additional businesses?
Yes No
Do you have insurance for the additional business?
Yes No
Do you own any farm, wooded or vacant Land? Yes No, If Yes, type #of acres
Are there any bodies of water on any insured premises? Yes No, describe
If there is a pond, lake or pool on premises is there “Use At Own Risk, No Diving” “No Lifeguard on Duty” signage? Yes No
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Are there any athletic fields or surfaces i.e. tennis courts, softball, volleyball etc. Yes No, describe
______
Do you own any watercraft? Yes No Type Length Horsepower
Is your watercraft insured elsewhere? Yes No, Carrier Name
Do you rent, loan or furnish any recreational equipment i.e. skis, bicycles, boats, mopeds, ATV’s, snowmobiles etc? Yes No:
describe
Alcoholic Beverages: Do you furnish or make them available? Yes No If yes: To guests only? Yes No
To guests and non-guests? Yes No Types: Wine Beer Liquor
Do you have a Liquor License? Yes No, Is a license required? Yes No Gross annual sales $
ARE YOU PROVIDING EITHER DIRECTLY OR THROUGH A PACKAGE
ANY OF THE ACTIVITIES LISTED BELOW:
**A copy of the hold harmless waiver used must be submitted prior to issuance of the policy for all activities**
Fishing, hunting, sightseeing, hot air ballooning or any other outdoor trip, tour, excursion or activity? Yes No
Snowmobiles, ATV’s or any other motorized craft?
Yes No
Tent sites, campgrounds or RV parking? Yes No
Work-out, tanning, athletic &/or playground equipment?
Yes No
Swimming pool, hot tub or whirlpool on premises? Yes No
Dance floor facilities?
Yes No
Day Care facilities? Yes No
Trampoline on premises?
Yes No
Horseback riding, carriage rides, sleigh rides, dog sledding, or any other activity using an animal to transport people? Yes No
Downhill skiing, tobogganing, sledding, or ice-skating?
Yes No
Inflatable tubes, canoes, kayaks, or rafts to navigate Class I or higher rapids?
Yes No
Massages or cosmetic services? Yes No
Professional services of any kind?
Yes No
Tour services, Describe type: Yes No
Are any of the above amenities offered to the public (non-guests)? Yes No
Explain all Yes:
______
PROVIDING ANY OF THE PACKAGES AND ACTIVITIES LISTED ABOVE MAY MAKE YOU INELIGIBLE FOR THIS PROGRAM
DO YOU UNDERSTAND THAT THE GUEST USE OF SWIMMING AREAS WITHOUT PROPER WARNING SIGNS AND THE USE
OF DIVING BOARDS, SLIDES, SWINGS, OR OTHER DEVICES WITHIN THE SWIMMING AREAS ARE PROHIBITED? Yes No
Do you hire any of the following, which are not covered by Worker's Compensation Insurance (answer each yes or no):
Employees that live on your premises Yes No , Independent contractors Yes No
If yes, explain
Coverage will become effective, if accepted, upon written notice by RPS and coverage will not commence earlier than the date received
in the office of RPS.
Applicant Statement: I understand that the amount of insurance applied for represents the current structure(s) described on this form.
Any modifications, improvements, new construction or alterations made hereafter will not be considered covered until I have properly
notified RPS the coverage limits have been reviewed and endorsed as necessary.
Applicant/Producer Statement: I hereby state I have been unable to procure the above requested coverage from standard insurers. I
request RPS to affect coverage and will be responsible for payment of premium, fees and taxes. I understand flat cancellations are not
permitted.
The Proposed insured warrants that the information provided on these applications is true, complete, and correct based on his/her
records, knowledge and belief. The Proposed Insured agrees that these applications shall constitute a part of any policy issued whether
attached or not and that any willful concealment or misrepresentation of a material fact or circumstance shall void any policy issued.
I understand coverage, if accepted, will become void at any time the covered property has been vacant or unoccupied for more than 60
days:
Signature of Agent or Broker Signature of Insured
Address Date
Phone & Fax Numbers Agent Code
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