Atlantic Risk Specialists, Inc.

LIMITED SERVICE FRANCHISED HOTEL APPLICATION

Corporate Name: ______

Name of Business (DBA):______

Mailing Address: ______

Premises Address: ______

Limit Requested (choose one): $5 Million  $10 Million  $15 Million 

Coverages: BLDG #1 BLDG #2 BLDG #3 BLDG #4

Units:
Stories:
Square Ft.
Construction
Year Built

Annual Receipts: Motel: $______Food: $______Liquor: $______

Average Room Rate: ______Average Occupancy Rate: ______

Guards: Armed  Unarmed  None 

Distance To Hydrant: ______Distance To Fire Department: ______

Sprinklered: Fully  Part ______%

Sprinkler: Wet  Dry 

Security Cameras: Yes_____No______

Electronic Locks: Yes_____ No______

Smoke Detectors: Hardwired: Yes______No______If Yes, is there a battery maintenance program in place? Yes______No______

Smoke Detectors Inside Rooms & Common Areas: Yes______No______

LIMITED SERVICE FRANCHISED HOTEL APPLICATION

Alarms: None  Fire  Burglar 

Fire Alarm Type:

Central Station/No WatchmanYes______No______

Central Station/WatchmanYes______No______

Local/No WatchmanYes______No______

Local/WatchmanYes______No______

NoneYes______No______

Watchman OnlyYes______No______

Parking Lot Type:

PrivateYes______No______

Public-Not Open AirYes______No______

Public-Open AirYes______No______

Are any rooms rented for 30 consecutive days?Yes______No______

If Yes, explain: ______

Years in Hotel Business______

Years in this Location______

Any GL/AL Losses over $50,000 in the past three (3) years: Yes______No______

Any Claims incurred involving the following:

1. Death Yes______No______

2. Brain Damage Yes______No______

3. Burns Over 50% Of The Body Yes______No______

4. Substantial Disfigurement Of The Body Yes______No______

5. Spinal Cord Injuries Involving Any Degree of Paralysis Yes______No______

6. Any Injury To A Minor Child Yes______No______

7. Any Assault and/or Robbery Yes______No______

8. Any Estimate of Damage In Excess of 50% Of The Underlying Limit Yes___ No___

General Hotel Questions

Aluminum WiringYes______No______

Certified Inspection NeededYes______No______

Emergency LightingYes______No______

Showers have Non-Slip SurfaceYes______No______

Gas or Tanks PresentYes______No______

Surge Protection PresentYes______No______

Lighting Rods PresentYes______No______

Deadbolts UsedYes______No______

KitchenettesYes______No______

Deposit three (3) or more times a weekYes______No______

LIMITED SERVICE FRANCHISED HOTEL APPLICATION

Rooms Open OutsideYes______No______

Enclosed StairwellsYes______No______

Owned AircraftYes______No______

Owned WatercraftYes______No______

Peep-Holes in doorsYes______No______

Acres of Vacant Land______

Cancelled last 3 years?Yes______No______

Number of exits per floor______

Manual Pull Alarm on each floor with Audible Alarm Device Yes______No______

Swimming Pool (choose one): None Inside Outside 

Diving Board Yes______No______

Depth marked Top & Edges Yes______No______

Water SlideYes______No______

Pool area locked after hoursYes______No______

FencedYes______No______

Pool chemicals checked regularlyYes______No______

Self-latching/closed GateYes______No______

LifeguardYes______No______

Open To Public or EmployeesYes______No______

Area supervised by Mgmt?Yes______No______

Rules PostedYes______No______

Locked Doors (Indoor)Yes______No______

RESTAURANTNone 

Is Restaurant in a Separate BuildingYes______No______

Is it a Franchise RestaurantYes______No______

Seating Capacity______

Is Liquor ServedYes______No______

Is there a Dance FloorYes______No______

Is Cooking Area Covered by DuctYes______No______

Is There an Automatic Fire Suppression SystemYes______No______

Is It Professionally Cleaned every three (3) monthsYes______No______

Suppression System Services Semi-AnnualYes______No______

Are Filters Cleaned WeeklyYes______No______

Is Entertainment ProvidedYes______No______

Any Catering/Vending Machine/Games/Admission/Gambling Yes_____ No_____

Weekday Hours- From: ______Weekend Hours- From: ______

Is Restaurant Leased OutYes______No______

Is Lounge Leased OutYes______No______

Night Club, Comedy Club, BarYes______No______

IF YES, PLEASE PROVIDE A COI FROM OWNER’S POLICY NAMING HOTEL/MOTEL AS ADDITIONAL INSURED

LIMITED SERVICE FRANCHISED HOTEL APPLICATION

AMENITIES

Jacuzzi Yes______No______

Racquet Ball Yes______No______

Steam Rom Yes______No______

Sauna Yes______No______

Meeting Room Yes______No______

Tennis/Basketball CourtsYes______No______

Day Care Yes______No______

Beauty/Barber Shop Yes______No______

Laundry/Dry Cleaning Yes______No______

ClubhouseYes______No______

Tanning BedsYes______No______

MarinaYes______No______

Golf CourseYes______No______

Babysitting ServicesYes______No______

Boating or FishingYes______No______

Construction ActivityYes______No______

Equipment RentalYes______No______

Exercise EquipmentYes______No______

Dog KennelYes______No______

Playground EquipmentYes______No______

Have all FIRE/IFE SAFETY REQUIREMENTS

been complied with (see attachment)? Yes______No______

Have all SWIMMING POOL & RESTAURANT

GUIDELINES been complied with (see attachment)? Yes____ No______

Insured/Owner Date

Agent/Authorized Representative

Date

SCHEDULE OF UNDERLYING INSURANCE

1. Is the GL Aggregate Limit Per Location?Yes_____No_____

If Yes, is the GL Aggregate Limit capped in any way?Yes_____No_____

If Yes, what is the cap limit? $______

2. Is the GL defense outside of policy limits?Yes_____No_____

3. Do all underlying CGL policy limits apply on a Per Location General Aggregate Basis? Yes_____ No_____

4. Are all underlying carriers rated A-VII or better by A.M. Best? Yes____ No____

Coverage / Insurer / Policy # / Limits / Premium / Policy Period
General Liability
Employers Liability
Liquor Liability
Other

AUTOMOBILE INFORMATION:

1. Non-Owned & Hired Auto- Explain any controls/procedures that are utilized by applicant to reduce its exposure and/or liability in regards to the use of employee or volunteer automobiles used on its behalf:

______

2. How are these vehicles used (e.g. errands, supplies?)

______

3. Radius: ______

4. What is the minimum age of the drivers? ______

5. Have any drivers been alleged or convicted of DUI, DWI or had their license suspended? Yes_____ No_____

______Agent/Authorized Representative Date

Page 1 of 5