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You can also download this application (PDF) and fax it to (609) 818 9535.

Questions

If you have any questions regarding this program or about the indication, you can contact Bill Cleave. We are committed to getting a Price Indication back to you in 1 business day.

Bill Cleave, President

Tel: (888) 392 6671

Hotel Excess Application

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Required fields

General Information
Submitting Agent Name: *
Agent Email: *

Effective Date:
Corporate Name:
Name of Business (& DBA):
Federal ID#:

Mailing Address:
Mailing Address 2:

Premises Address:
Premises Address 2:
County:
Contact Person: *
Contact Phone: *
E-mail Address:
Website:

Limit Requested:	$5 Million $10 Million $15 Million

Property Information
	Bldg #1	Bldg #2	Bldg #3	Bldg #4	Bldg #5
# of Units:
# of Stories:
Square Feet:
Type Construction:
Year Built:

Additional Questions
Annual Lodging Receipts:	$	Average Room Rate:
Annual Food Receipts:	$	Average Occupancy Rate:	%
Annual Liquor Receipts:	$	Guards:	None Unarmed Armed
Distance to Fire Hydrant:	ft.	Distance to Fire Dept:	miles
Sprinklered:	Fully Part 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
Are Smoke Detectors Inside Rooms & Common Areas?:			Yes No

ALARMS
Alarms: None Fire Burglar
Fire Alarm Type:
Central Station / No Watchman:	Yes No	Central Station / Watchman:	Yes No
Local / No Watchman:	Yes No	Local / Watchman:	Yes No
Watchman Only:	Yes No	None:	Yes No
PARKING LOT TYPE
Private:	Yes No
Public-Not Open Air:	Yes No
Public-Open Air:	Yes No

Are any rooms rented for 30 consecutive days?		Yes No
If Yes, explain:

Years in Hotel Business:		Years in this Location:

GL/AL LOSSES
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 Wiring?:	Yes No	Enclosed Stairwells?	Yes No
Certified Inspection Needed?	Yes No	Emergency Lighting?	Yes No
Showers Have Non-Slip Surface?	Yes No	Gas or Tanks Present?	Yes No
Surge Protection Present?	Yes No	Lightning Rods Present?	Yes No
Deadbolts Used?	Yes No	Kitchenettes?	Yes No
Manual Pull Alarm on Each Floor with Audible Alarm Device?	Yes No	Owned Aircraft?	Yes No
# Exits Per Floor?		Owned Watercraft?	Yes No
Smoke Detectors Inside Rooms?	Yes No	Rooms Open to Outside?	Yes No
Peep-Holes in Doors?	Yes No	# of Elevators?
Deposit Receipts >3 Times/Week?	Yes No	Acres of Vacant Land?

Swimming Pool
Swimming Pool?	Yes No
Depth Posted on Top & Edge?	Yes No	Lifeguard?	Yes No
Water Slide?	Yes No	Diving Board?	Yes No
Locked Doors (Indoor)?	Yes No	Fenced Pool?	Yes No
Self-Latching Gate?	Yes No	Pool Rules Posted?	Yes No
Pool Open to Public or Employees?	Yes No	Pool Locked After Hours?	Yes No
Pool Chemicals Checked Regularly?	Yes No	Children Allowed in Pool?	Yes No
Area Supervised by Mgmt?	Yes No

Restaurant Information
Restaurant?	Yes No
Restaurant a Separate Bldg?	Yes No	Is it a Franchise Restaurant?	Yes No
Square Footage Restaurant?		Seating Capacity?	Yes No
Liquor Served?	Yes No	Suppression System Srvs Semi-Annual?	Yes No
Dance Floor?	Yes No	Square Footage of Dance Floor:	Yes No
Cooking Area Covered by Duct?	Yes No	Automatic Fire Suppression System?	Yes No
Is it Professionally Cleaned Every 3 MNs?	Yes No	Is Restaurant Leased Out?	Yes No
Night Club, Comedy Club, Bar?	Yes No	Is Lounge Leased Out?	Yes No
Filters Cleaned Weekly?	Yes No	Entertainment Provided?	Yes No
Any Catering/ Vending/Games?	Yes No	Admission Charged/Gambling?	Yes No
Weekday Hours:		Weekend Hours:

Amenities
Jacuzzi:	Yes No	Racquet Ball?	Yes No
Steam Room?	Yes No	Sauna?	Yes No
Meeting Room?	Yes No	Tennis Courts?	Yes No
Golf Course?	Yes No	Boating or Fishing?	Yes No
Equipment Rental?	Yes No	Dog Kennel?	Yes No
Marina?	Yes No	Babysitting Services?	Yes No
Day Care?	Yes No	Beauty or Barber Shop?	Yes No
Laundry or Dry Cleaner?	Yes No	Clubhouse?	Yes No
Tanning Beds?	Yes No	Construction Activity?	Yes No
Exercise Equipment?	Yes No	Playground Equipment?	Yes No
Have all FIRE/LIFE SAFETY REQUIREMENTS been complied with (see tab marked "Fire/Life Safety Requirements")?			Yes No
Have all SWIMMING POOL & RESTAURANT GUIDELINES been complied with (see tab marked "Swimming Pool/Restaurant Guidleines")?			Yes No

Schedule of Underlying Coverages
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?
Is the GL defense outside of policy limits?				Yes No
Do all underlying CGL policy limits apply on a Per Location General Aggregate Basis?				Yes No
Are all underlying carriers rated A-VII or better by A.M. Best?				Yes No

	Insurer	Policy No.	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: miles
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

Additional Comments or Questions

I understand that by selecting this checkbox, I vouch that the above is accurate and correct.

Type Your Full Name to Sign: *
Today's Date: *

A signed and dated application will be required to bind any quote.

Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

* Umbrellas currently available in all states except Alaska.

** Acceptability subject to review. Platinum Leisure RPG only open to franchised hotels/motels with certain stipulations. For example, liquor receipts should be no greater than 20% to 25% of restaurant receipts. In addition, restaurants should be attached. Further, up to two (2) owned autos are covered, but passenger transport is excluded.. Other exceptions apply.

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