Fillable SPECIALTY APPLICATION Bed & Breakfast/Vacation Rental/Owner Event Venue (Risk Placement Services, Inc.)

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SPECIALTY APPLICATION Bed & Breakfast/Vacation Rental/Owner Event Venue (Risk Placement Services, Inc.)

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BNB/CBB 10/17
1 of 4
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
BNB/CBB 10/17
2 of 4
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 $
BNB/CBB 10/17
3 of 4
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
BNB/CBB 10/17
4 of 4
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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SPECIALTY APPLICATION Bed & BreakfastVacation RentalOwner Event Venue (Risk Placement Services, Inc.)

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Completed 30 July 2020

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