Supplemental Application Hotels & Motels
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1 Supplemental Application Hotels & Motels Applicant Name: Location Address: Web Site: Date: Business Information: Years experience of mgmt. at this location: Total years experience in this industry: Any prior bankruptcies or liquidations? Describe: Premises Information: Number of rooms: Average room rate: Number of buildings at this location: Occupancy rate: Hour/Day/Week/Month: Minimum distance between buildings: When were updates for: - Electricity: Partial or complete? - Plumbing: Partial or complete? - Roofing: Partial or complete? - HVAC: Partial or complete? Are buildings sprinklered? Percentage: Are there smoke detectors? Hard wired or battery operated? Are there fire alarms? Central station, local or pull alarms? Is there aluminum wiring on premises? Describe: Is the aluminum wiring repaired? Describe: Clearly marked fire exits? Emergency lighting in common areas? Secondary means of egress for each floor? Dead bolt locks on doors to units? Are the locks re-keyed after occupancy? Are there elevators? Do you have an agreement with elevator company? Is there a parking lot located on premises? Is the parking lot owned, operated & maintained by applicant? What is the size of the parking lot? Is there a valet parking service? Is the valet parking provided by an independent service company? Is the valet service required to maintain indemnity insurance? 2006 Apex Insurance Managers, LLC 1 Hotels & Motels (01/01/06)
2 Pools: Check here if no Pools How many swimming pools? Are there any hot tubs? Do pools have self-latching doors or gates? Are there any diving boards or slides? Describe: Are there life guards on duty? How often? Is there rescue equipment such as a ring buoy, shepherds hook or pole? Are pool depths adequately marked? Are pool chemicals properly stored? Is there an automatic shutoff? Recreational Facilities: Check here if no Recreational Facilities Is there a playground? Is it fenced? Are there any lakes, ponds or boat slips? Describe: Are there any exercise facilities? Describe: Are there any daycare services? Describe: Are there any tennis, basketball or racquetball courts? Describe: Are there any saunas? Describe: Are there any recreational equipment rentals/checkouts? Describe: Restaurant/Cooking Exposure: Check here if no Cooking Exposure Any sub-contracted cooking facilities? Is indemnity ins. required? Type of cooking - Deep Fat Fryers? - Griddles? - Grill/BBQ Pit? Does establishment serve any raw seafood? Describe: Are there any banquet facilities? Square footage: Maximum occupancy: Any off-premises catering? Describe: Is there an automatic suppression system Is there an automatic shutoff? over all cooking surfaces? Is there an independent cleaning contract for hoods & ducts? How often is system cleaned? Have there been any Health Dept. violations? Describe: 2006 Apex Insurance Managers, LLC 2 Hotels & Motels (01/01/06)
3 Liquor Liability: Check here if no Liquor is sold or furnished Have you ever had your liquor license revoked or suspended? Any prior liquor citations or law violations? Do all servers receive formal Alcohol Awareness training? Do you sponsor any drink specials (i.e., 2-for-1, ladies night, etc.)? Describe: Describe: Describe: Describe: Do you have any package sales? Describe: Do you have any drive-thru facilities? Describe: Do you admit anyone under 21? Describe: Age of clientele (percentages): Are patrons allowed to bring in their own alcoholic beverages? Are you open later than other establishments in the area? Do you provide cab service or have a designated driver program? Is there any off-premises liquor catering? Under thru thru 40 Over 40 Bar/Lounge: Check here if no Bar/Lounge Hours of operation: Mon. Thu. Fri. Sat. Sun. Is there a dance floor? Sq. footage: Are there any mechanical devices? Describe: Are there any gambling devices or tables? Describe: Are there any pool or billiards tables? Describe: Are there any athletic events? Describe: Are there any promotional events (such as Teen Night, Wet T-Shirt or Foam Describe: Contests)? Are there any special activities (such as mud wrestling, bungee jumping, Describe: Velcro suits or mosh pits)? Other special or promotional activities? Describe: 2006 Apex Insurance Managers, LLC 3 Hotels & Motels (01/01/06)
4 LIVE Entertainment: Check here if no LIVE Entertainment Is there a DJ or karaoke? Describe: Is there any topless or Go-Go dancing? Describe: Are there any comedians or stand-up entertainers? Describe: Any live performers: - Country?. nights per - Piano/Solo Acts?. nights per - Rock/Disco?. nights per - Other?. nights per Are there any national known performers? Describe: Are there any promoters? Describe: Any special effects: - Lighting/Sound? - Smoke? - Pyrotechnics? Other live entertainment? Describe: Security: Are there any employee bouncers or security guards? Are there any third-party bouncers or security guards? Are there any off-duty uniformed policemen? Are there any ID checkers? Describe: Are there any weapons on premises? Describe: Gross Receipts: Hotel Operations Bar/Lounge Restaurant Sales/receipts Food Food Rentals Liquor Liquor Other Catering Catering Total Total Total 2006 Apex Insurance Managers, LLC 4 Hotels & Motels (01/01/06)
5 Representation & Warranty Statement: I have read this Application and I represent that all of the foregoing statements are true and accurate and that these statements are offered as the basis upon which Apex is considering issuance of an insurance policy. Any missing or erroneous information in this Application may jeopardize coverage in the event of a claim under any policy issued by Apex. 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 a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant: Title: Date: 2006 Apex Insurance Managers, LLC 5 Hotels & Motels (01/01/06)
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COMPANY NAME CONTACT NAME TELEPHONE NUMBER DENIAL REASON APPLICANT S MAILING ADDRESS: CITY STATE COUNTY ZIP TELEPHONE
DWELLING FIRE / HOMEOWNERS PROPERTY INSURANCE APPLICATION Indiana Basic Property Insurance Underwriting Association 8777 Purdue Road, Suite 360, Indianapolis, IN 46268 (317) 264-2310 or (800) 888-8627
7 TOW TRUCK PROGRAM SUPPLEMENTAL APPLICATION
LICATION Named Insured: Owner s Name: Web site Address: Address: Type of business Individual Corporation LLC Other Federal Tax ID: I. ELIGIBILITY 1. Are at least 50% of the operations derived towing? Yes
Substantially incomplete submissions will be declined
CONTRACTORS POLLUTION LIABILITY FOR FIRE/WATER RESTORATION CONTRACTORS APPLICATION REQUIREMENTS 1. Contractors Pollution Liability Application - complete all questions in full. 2. Special attention should
CONTRACTORS GENERAL LIABILITY APPLICATION Note: Throughout this questionnaire the words you and your include all entities seeking coverage
CONTRACTORS BEST INSURANCE SERVICES INC. 20335 Ventura Blvd., Ste 426, Woodland Hills, CA 91364 Phone No: 818-348-4900 FAX No: 866-309-9237 CA License #0F37560 CONTRACTORS GENERAL LIABILITY APPLICATION
HOMEOWNERS/DWELLING FIRE DISCOVERY QUESTIONNAIRE
U.S. Licensed Producer/Broker ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS
AUTO SERVICE RISKS GENERAL LIABILITY APPLICATION
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
SPECIALTY E&O PLAN APPLICATION FOR SPECIALTY ERRORS AND OMISSIONS LIABILITY INSURANCE POLICY Underwriting and Claims Manager: Media/Professional Insurance SPECIALTY E&O PLAN APPLICATION FOR SPECIALTY ERRORS