8877 North Gainey Center Drive • Scottsdale, Arizona85258

1-800-423-7675 • Fax (480) 483-6752

Motel Program Supplemental Application

(Complete in addition to ACORD General Liability Application)

Name of Applicant:______

1.Operation:

 Hotel Motel Tourist Courts/Cabins Resort Dude Ranch

 Other (describe):______

Number of rooms:______Average room charge:______Average occupancy rate:______%

Room rental by the:HourDayWeekMonthOther (describe):______

Any leased areas?...... YesNo

Leased to whom?______

Operation:______Area:______Sq. Ft.

2.National affiliation?...... YesNo

If yes, with whom?______

3.Recommended by local Chamber of Commerce or American Automobile Association (AAA)?...... YesNo

4.Building information/protection:

Number of stories:______Construction:______

Central station fire alarmLocal fire alarmEmergency lightingGuardsSprinklered

Standpipes and hoseGuest rooms have smoke detectors

5.Annual gross sales for insured's 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 of above

6.Other operations/exposures:

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Baseball fields

Number of fields:______

Sports courts (tennis, basketball, racquetball, volleyball, etc.)

Total number of courts:______

Trails

Bike—Number of trail miles:______

Horse— Number of trail miles:______

Other (describe):______

6.Other operations/exposures (continued):

Boats

Number of boats:______

Type (sail, power, canoe, etc.):______

Boat docks or slips

Number:______

Club houses (including exercise rooms)

Square footage:______

Lake

Number of acres:______

Park

Number of acres:______

Playgrounds

Number of playgrounds:______

Saddle animals

Number and describe type of animal:______

Saunas/hot tubs

Number of saunas and hot tubs:______

Security guards

Number employed:______

Number of independent contractors:______

Are they:armedunarmed

Skeet/trap/archery ranges

Number of ranges:______

Spas

Number of spas:______

Swimming

Indoor pool

Number of pools:______

Outdoor pool

(In-groundAbove-ground)

Number of pools:______

Bathing beach

(Ocean beachLake/river beach)

Number of beaches:______

Number of diving boards/slides/rafts:______

Board/slide height:______ft.

Swimming rules posted?...... YesNo

Is outdoor, in-ground pool fenced with a self-latching gate or surrounded by the building with no direct access to roadways or parking areas? YesNo

Life-safety equipment available at pool side?..YesNo

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GLH-APP-48s (3-02)

7.Describe any additional recreational facilities operated by you or others on the premises:______

______

______

8.Security:

Employees are required to wear ID badges at all times...... YesNo

Room doors have viewing devices (peep holes)...... YesNo

Room doors have deadbolt locks and door chains...... YesNo

Door keys are card keys for electronic locks...... YesNo

Adjoining room doors have deadbolt locks...... YesNo

Sliding glass doors have security bars or poles within door tracks...... YesNo

Do you release guest names and room numbers to others?...... YesNo

Do rooms contain security instructions for guests?...... YesNo

Facility has CCTV for monitoring parking and entrances...... YesNo

9.Innkeepers liability limit:

$1,000 per occurrence/$10,000 aggregate

$2,500 per occurrence/$25,000 aggregate

APPLICABLE IN THE STATE OF NEW YORK:

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.

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.

PRODUCER’S SIGNATURE:______Date:______

APPLICANT’S SIGNATURE:______Date:______

AGENT NAME:______AGENT LICENSE NUMBER:______

(Applicable to Florida Agents Only.)

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