Woodall & Hoggle Insurance Agency Inc.

GENERAL INFORMATION

Applicant Name:

Proposed Effective Date:

DBA:

Address:

City:

State:

Zip Code:

Contact:

Phone:

Email:

How many years has the premises been owned?

Who manages the hotel? Owner Hired Management

How many years hotel management experience?

Total number of employees: Full Time Part Time

List any hospitality related associations in which you are a member:

Do you presently own or operate any other hotel or involved with any other business for which you are not applying for coverage under this application?
Yes No
If yes, please explain:

Have you, or any other person for whom coverage is being requested, had any liability applications denied, policies cancelled,or policies non
renewed in the past three (3) years? Yes No
If yes, please explain:

Are you, or any other person for whom coverage is being requested, aware of any circumstances, which may result in a claim?
Yes No
If yes, please explain:

Are you required to name any other person or entity as an additional insured on your policy?
Yes No
If yes, please provide name, address and interest:

Section 2: Underwriting Information

Please provide the following information:

Number of Rooms:

Average Room Rate : $

Average Occupancy Rate %:

Annual Room Sales : $

Building Information:

Number of stories:

Year Built:

If Renovated, what year?

Construction Type:

Square Footage:

Distance to Fire Dept:

Distance to Fire Hydrant:: Distance to Ocean:

Does your hotel have interior or exterior corridors? Interior Exterior

Does your hotel have any elevators? Yes No

Do you have an elevator maintenance contract in place? Yes No

Is there emergency lighting in all corridors and stairways? Yes No

Is the hotel sprinklered? Yes No
If yes, what percentage?

Is there a current sprinkler system service contract in place? Yes No

Have all fire extinguishers been inspected or purchased within the past 12 months? Yes No

Are there smoke detectors in all common areas? Yes No

In all guest rooms? Yes No

Are smoke detectors Hardwired Battery

If battery operated, how often are they checked?

Have there been any property related claims in the past 3 years? Yes No

If yes, please explain details with amounts paid:

Limits of Coverage:

Building : $

Business Personal Property : $

Signage : $

Loss of Income: $

Guest Rooms:

What type of key system is used? Manual Electric

Do all rooms have:
Peepholes Yes No Dead Bolts Yes No Metal Chain Locks Yes No Swing Bars Yes No

Do all bathtubs have:
Non-Slip Surfaces Yes No Bath Mats Yes No Grab Bars Yes No

Are any rooms equipped with kitchenettes and/or is cooking permitted? Yes No

General Liability:

Limit of Liability:

Innkeepers Liability:

Have there been any general liability claims in the past 3 years? Yes No

If so, please explain details with amounts paid:

Premises/Operations

Does anyone other than the owner or manager live on site? Yes No
If so, please explain:

Are there any long term rentals (thirty days and more)? Yes No
If yes, please explain: (include how many)

Does the hotel have BBQ grills on premises? Yes No

Are they regularly inspected for saftely and maintenance: Yes No

Are instructions and rules posted for usage? Yes No

Are all public areas including sidewalks and parking lots free from defects? Yes No

Are there security guards on premises? Yes No

If yes, how many? Are they armed? Yes No

Are guards: Employees Contracted What are the hours guards are present?

Do all secondary exterior doors require use of a key to enter? Yes No

Is the premises covered by security cameras? Yes No

Swimming Pools

Number of swimming pools(s) on premises Outdoor Indoor

Are pools operational? Yes No

If not, is pool covered, fenced and locked? Yes No

Is the use of pools limited to hotel guest only? Yes No

Are pools fenced with a self-latching and self-closing gate? Yes No

Are pool safety rules posted at the entrance and within pool area? Yes No

How often is the pool water tested?

Is testing completed by: Employees Contracted

Are all pool/hot tub water tests documented and logs maintained on site? Yes No

Are depths clearly marked on the top and sides of the pool? Yes No

Is underwater lighting in the pool protected by either a GFIC of under 15 volt circuit? Yes No

Is rescue equipment located within the pool are (ring buoys, life hooks)? Yes No

Is there a diving board? Yes No Is there a pool slide? Yes No

Fitness Center

Is the use of the fitness center restricted to adults? Yes No

Is the use of the fitness center limited to hotel guests only? Yes No

Are rules posted within the fitness center? Yes No

Section 3: Automobile

Limit of Liability: $

Hired & Non Owned Liability Limit: $

Does the insured have any owned commecial autos: Yes No
If so please give year, make, model and VIN#:

Do you provide valet service? Yes No If yes Owner Operated Contracted

If provided by employees, do they have garage keepers liability? Yes No

Do you provide a guest shuttle service? Yes No If yes Owner Operated Contracted

If either of the above are cotnracted, do you require certificates of insurance naming you as an additional insured? Yes No

Do you, your employees, or anyone else use their own vehicles for business purposes? Yes No

If yes, please explain:

Section 4: Recreational

Do you provide any of the following:
Playground Yes No Lake or River Exposure Yes No Piers or Docks Yes No
Marina Yes No Loaned Recreational Equipment Yes No

Is there any other activity not mentions that takes place on premises? Yes No

If yes, please describe:

Section 4: Workers Compensations

Projected annual payroll by classification:

Federal ID #

Are owners/officers included or excluded from coverage? Included Excluded

Current Insurance Carrier:

Have there been any workers compensation related claims in the past 3 years? Yes No

if yes, please give details with amounts paid:

Applicant warrants that the above information is true and complete. Applicant understands that the insureer will rely on this information for purposes of acting
on this application for insurance. The provision of false information on an application is insurance fraud, which is a crime in many states and could void
coverage applied for in this application.

Hotel Application