B+B Resorts App Bed Rider 822 Adven Sure BBResorts
User Manual: Bed Rider 822
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P.O. Box 5670 Cortland, NY 13045 Phone: (800) 822-3747 Fax: (607) 756-5051 BED & BREAKFAST/RESORTS APPLICATION GENERAL INFORMATION Date of survey: ___ Insurance Renewal Date: _____________ Date proposal needed: Legal Name of Organization: FEIN: (Please include all organizations that are to be included as insureds) Mailing Address: County: Location Address: County: Telephone: Fax: Contact Name: Contact Title: Website Address: E-Mail Address: INSURANCE AGENT INFORMATION Agent’s Name: Name of Agency: Address: Telephone: Fax: _ Do you currently write this account? Yes _ E-mail address: ___________________ __ No If yes, for how long? _________________ Is the account Sub-Brokered? Yes Carrier Name? _______________________________ No If yes, please indicate Agency Name: BUSINESS INFORMATION Which best describes the organization (please check one): Bed & Breakfast Country Inn Destination Resort Lodge Other (please describe): Description of organization: Sole Proprietorship Partnership Corporation Years in operation: Total # of Guides/Outfitters: Other (Minimum Requirement: 3 Years in Operation) Total # of Guests expected this year: Average trip duration: days Is your business currently up for sale? Yes No Has your business had any changes in ownership over the past 3 years? If so please provide details: Yes No Has your business filed for bankruptcy and/or been in receivership within the last 3 years? Yes No Has any insurance carrier cancelled, declined or refused to renew any insurance within the past 3 years? If yes, please provide dates, coverage and explanation: Yes No Are you a member of any state or regional association? Yes No If yes, please list: Edition 03/10 AdvenSure Bed & Breakfast Application Page 1 LOCATION INFORMATION Please complete and attach a property ACORD application if property coverage is desired. What fire control water sources are available? Fire Hydrant Pool Pond/Lake Water Tank Other, please specify: Are there buildings at your facility with limited access due to forest, terrain or season? Yes No Are your buildings located in heavily wooded areas? Yes No Is the clearing from forest/wooded areas greater than 150 feet? Yes No Are your buildings occupied year round? Yes No If no, is there a caretaker on site? Yes No If no, are buildings winterized? Yes No Are there smoke alarms in all corridors and sleeping quarters? Yes No Is your building equipped with sprinklers? Yes No Is there emergency lighting in all corridors and sleeping quarters? Yes No Do you have two means of egress from all floors? Yes No Do any buildings have wood burning fireplaces and/or woodstoves? Yes No Yes No Do you allow smoking inside your buildings? Yes No Cooking Facility Information Do you have an automatic extinguishing system over the cooking surface? Yes No Do you have automatic fuel shut-offs to stoves? Yes No Do you have deep fat fryers? Yes No Do you have a hood and duct system? Yes No Yes No Yes No Does the water around your dock freeze? Yes No Are the docks removed? Yes No If yes, list location numbers: Do any buildings have any ACTIVE Knob & Tube and/or Aluminum wiring? If yes, list location numbers: If yes, is there a formal maintenance contract in place? Do you have fire extinguishers readily available? Dock Information If requesting property coverage for docks please provide pictures and answer the following questions: Indicate the number of Docks Indicate the number of Boat Slips Edition 03/10 AdvenSure Bed & Breakfast Application Page 2 CGL LIMITS OF INSURANCE Each Occurrence/General Aggregate $300,000/$600,000 $500,000/$1 million $1 million/$2 million $1 million/$3 million Damage to Rented Premises $100,000 Medical Payments $5,000 Employee Benefits Liability** $300,000/$600,000 $500,000/$1 million $1 million/$2 million Retroactive Date: $1 million/$3 million (claims made only) **Employee Benefits Liability not available in MT, NY and TX CERTIFICATES OF INSURANCE & ADDITIONAL INSUREDS List any entities that need Certificates of Insurance or Additional Insured endorsements for liability coverage. For Additional Insureds, describe their interest in your business. Loc. No. Name & Address Certificate of Insurance Additional Insured Describe Interest Describe Interest OPERATIONS Is your business open year round? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Do you allow your guests to bring pets? Yes No Is there a formal maintenance program for the grounds and public traffic areas? Yes No Do you sell alcohol? If yes, please complete and attach the Liquor Supplement. Yes No If no, provide the number of months you are open? Do you or a manager live on the premise? If yes, is there separate homeowners or tenants coverage in place? If no, please complete the Personal Liability Supplement. Is staff on premise while guests are present? If no, are guests provided with emergency contact information? Do you have any dogs on the premise (other than those owned by your guests)? If yes: What breed(s)? Are your dogs ever allowed into guest areas or around guests? Edition 03/10 AdvenSure Bed & Breakfast Application Page 3 SUBCONTRACTOR INFORMATION Does the organization hire subcontractors? If yes, are certificates of insurance obtained from all subcontractors? Yes No Yes No Please describe the work performed by all subcontractors and indicate the annual cost for this work: Work Performed Cost $ Work Performed Cost $ List Safety Procedures and attach safety guidelines: ACTIVITIES CONDUCTED Expiring Policy estimated total receipts: $ Next 12 month’s estimated total receipts: $ Do you require guests and/or visitors to sign an acknowledgment of risk or liability waiver? Activities Conducted Guided ATV/Snowmobile Operations (complete section below) Yes No Revenue $ Cross Country Skiing/Snowshoeing Day Care/Babysitting Operations Downhill Skiing Hay/Sleigh/Wagon Rides (complete section below) Hiking/Backpacking Horseback Riding/Rodeo (complete section below) Mountain Biking/Road Cycling (complete section below) Mountain/Rock Climbing Pools/Swimming Areas (complete section below) Restaurant/Snack Bar (complete section below) $ Retail Operations (complete section below) $ Special Events (complete section below) $ Tour Operations (complete section below) $ Watercraft (complete section below) $ What activities, other than those identified above, are conducted or take place at your business? If guided services are provided, please answer the following: What is the minimum experience level of your guides? Years Have your guides received first aid training? Yes No Do your guides carry a means of communication (cell phone, 2-way radios, etc.)? Yes No Edition 03/10 AdvenSure Bed & Breakfast Application Page 4 ATV/SNOWMOBILE OPERATIONS What percentage of your ATV/Snowmobile operations is unguided? % Do you rent or supply ATVs/Snowmobiles to your guests? Yes No Are helmets required? Yes No Are helmets provided to your guests? Yes No Do you conduct a pre-ride safety briefing with guests? Yes No Is there a formal maintenance program for owned ATVs/Snowmobiles? Yes No Do you provide mechanical service and/or sell mechanical parts for non-owned ATVs/Snowmobiles? Yes No Do you provide trailer hitch fabrication or installation? Yes No HAY/SLEIGH/WAGON RIDES Ride Type: Wagon Sleigh Surrey Buckboard/Buggy Conveyance Type: Tractor Horse Other: Rides take place on: Public Roads Public Areas Private Land (your premise) Other: Maximum Number of Passengers: Are rides operated and/or supervised by employees? Yes No Do you require the use of helmets for all riders age 12 and under? Yes No Do you ever allow double riding? Yes No Do you operate pony rides? Yes No Yes No Do you ever participate in parades or community celebrations with your horses? Yes No Do you board horses other than those owned by yourself or your guests? Yes No Do you hold rodeos or other competitive events? Yes No Yes No Yes No Do you allow your guests to rope or brand cattle? Yes No Do you conduct a pre-ride safety briefing with guests? Yes No Do you provide a written safety manual outlining procedures to staff members? Yes No HORSEBACK RIDING/RODEO INFORMATION What percentage of your riding operations is unguided? % What is the total number of horses available for guest riding? What is the youngest rider you will allow on a horse? years old If yes, is the pony hand led? What is the youngest rider you will allow on a pony? years old If yes, do you allow your guests to participate? Do you conduct cattle drives? If yes, what is the wrangler to rider ratio? / List any reasons why you would decline a person from riding (health, age, alcohol, etc). Edition 03/10 AdvenSure Bed & Breakfast Application Page 5 MOUNTAIN BIKING/ROAD CYCLING INFORMATION What percentage of your cycling operations is unguided? % Do you rent or supply bicycles to your guests? Yes No Are helmets required? Yes No Are helmets provided to your guests? Yes No Do you conduct a pre-ride safety briefing with guests? Yes No Are your swimming facilities open to the general public? Yes No Are pool areas fenced? Yes No Yes No Are all other swimming areas roped off or clearly defined? Yes No Is the depth of the swimming area clearly marked? Yes No Are life rings or buoys provided? Yes No Is there a lifeguard on duty? Yes No Yes No Is a trained employee available for emergencies? Yes No Do you have any diving boards? Yes No Do you have a waterslide? Yes No Yes No What percentages of tours are: Off-road: % On-road: % POOL & SWIMMING AREAS How many of each: Pools Lakes/Ponds Other: please specify: If yes, does it have a childproof, self-locking gate? If no, is there a sign indicating “No lifeguard, swim at your own risk, no diving”? If yes, what is the length & height of the slide? Length Height RESTAURANT/SNACK BAR OPERATIONS What best describes your food establishment? Snack Bar Only Restaurant with Table Service Restaurant without Table Service Do you sell alcohol? If yes, please complete the Liquor Supplement. If yes, what percent of restaurant sales is generated from the sale of alcohol? What percent of sales are generated from non-lodging patrons? Edition 03/10 % % AdvenSure Bed & Breakfast Application Page 6 RETAIL OPERATIONS What is the total value of retail inventory? $ What type of inventory do you sell? (Check all that apply): General Merchandise Baked/Homemade Goods Souvenirs Sporting Goods Other: Do you import directly from any foreign manufacturers? Yes No Yes No Yes No If yes, please provide certificates of insurance evidencing foreign manufacturer’s products liability insurance. In U.S. dollars, what is the limit of their products liability insurance? $ Do you obtain certificates of insurance for products liability insurance from U.S. manufacturers of your products? If yes, please provide copies of certificates. If No, it is essential that you make every attempt to. Are you a “Vendor” on the Products Liability Insurance carried by the U.S. manufacturers of your products? If yes, please provide copies of certificates. If No, it is essential that you make every attempt to. What other types of retail operations take place at your business? SPECIAL EVENT INFORMATION Do you hold any of the following events? (Please check all the apply) Banquets Conferences Weddings/Reunions Other, please specify: Do you provide the catering at these functions? Yes No Do you sell alcohol at any of these functions? Yes No If yes, please complete the Liquor Supplement TOUR INFORMATION What types of tours are provided? (Check all the apply) Historic Scenic Other: What modes of transportation are used? (Check all the apply) ATVs/Snowmobiles What is the tour guide to guest ratio? Edition 03/10 Boat Bus/Vehicle Hiking Horses Other: / AdvenSure Bed & Breakfast Application Page 7 WATERCRAFT What percentage of your watercraft operations is unguided? % On what type of water does use take place? (Please check all that apply). Rivers Lakes/Ponds Ocean Bays/Inlets If use takes place on rivers, what is the river classification(s)? Class I Class II Class III Class IV Class V Are life vests/personal floatation devices required? Yes No Are life vests/personal floatation devices provided to your guests? Yes No Do you permit water skiing with the use of your watercraft? Yes No Do you provide, rent, lease or operate any personal watercraft? (IE: Jet Skis, Sea-Doos and/or Waverunners) Yes No Non-Motorized Watercraft Boat Type Number Used Canoes/Kayaks Row Boats/Paddle Boats Float Tubes/Rafts Motorized Watercraft Year Make & Model Length HP OB / IB / IO # Pass Guest Operated Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No **If physical damage/hull coverage is required, please attach the applicable ACORD application** Edition 03/10 AdvenSure Bed & Breakfast Application Page 8 EXCESS LIABILITY Desired Limit of Insurance (maximum $5 million): $ Please note that the minimum underlying limits are $1 million per occurrence/$2 million annual aggregate for Commercial General Liability, $1 million CSL for Auto Liability, and $1million bodily injury by accident/$1 million bodily injury by disease/$1 million bodily injury by disease policy limit for Employers Liability if provided. Please indicate the following underlying coverage information for Employers Liability. If this information is not provided, Excess Employers Liability coverage will not be included. Insurer*: Policy Number: Policy Period: Employers Liability (Coverage B) Limits: $ Bodily Injury by Accident $ Bodily Injury by Disease $ BI by Disease Policy Limit *Excess Employers Liability is subject to approval of the insurer providing the underlying coverage. ADDITIONAL COVERAGES AVAILABLE For Business Automobile, Commercial Crime and/or Inland Marine, please attach applicable ACORD applications. PREMIUM HISTORY Please indicate the Total Account Premium for the past 3 years. Carrier(s): $ Carrier(s): $ Carrier(s): $ (current year) (1st prior year) (2nd prior year) Claims History Have there been any claims or losses in the last five years: Yes No If yes, please indicate all known claims and losses for the past five years, and any pending incidents that could result in a claim being made against the organization. Include the date of loss, a short description of the claim, the status of the claim (open/closed), and the dollar amounts paid or reserved.* DOL Description Status Amount *Attach separate pages if needed. Provide the carrier loss runs if available Edition 03/10 AdvenSure Bed & Breakfast Application Page 9 SUBMISSION REQUIREMENTS Attachments to this application must include the following: • A complete drivers list with driver names, license numbers, dates of birth and date of hire (if auto coverage requested). • All available brochures. • Copies of waivers currently in use. A quotation will not be offered if the attachments are not included with the application. APPLICATION SIGNATURES & STATE FRAUD STATEMENTS APPLICABLE IN ARIZONA - ARIZONA FRAUD STATEMENT For your protection Arizona law requires the following statement to appear on this form, any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. APPLICABLE IN ARKANSAS - ARKANSAS FRAUD STATEMENT Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding workers compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for either of said purposes, under this chapter shall be guilty of a Class D felony. APPLICABLE IN CALIFORNIA - CALIFORNIA FRAUD STATEMENT For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. APPLICABLE IN COLORADO - COLORADO FRAUD STATEMENT It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. APPLICABLE IN DELAWARE - DELAWARE FRAUD STATEMENT Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN IDAHO – IDAHO FRAUD STATEMENT Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete, or misleading information is guilty of a felony. APPLICABLE IN INDIANA – INDIANA FRAUD STATEMENT Any person who knowingly, and with intent to defraud an insurer, files a statement of claim containing false, incomplete or misleading information commits a felony. APPLICABLE IN KENTUCKY - KENTUCKY FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. APPLICABLE IN LOUISIANA - LOUISIANA FRAUD STATEMENT Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN MAINE – MAINE FRAUD STATEMENT It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines or a denial of insurance benefits. APPLICABLE IN MARYLAND – MARYLAND FRAUD STATEMENT Any person who knowingly and willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN MINNESOTA – MINNESOTA FRAUD STATEMENT A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN NEBRASKA – NEBRASKA FRAUD STATEMENT 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 may subject the person to criminal and civil penalties. APPLICABLE IN NEW HAMPSHIRE – NEW HAMPSHIRE FRAUD STATEMENT Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in R.S.A. 638.20. Edition 03/10 AdvenSure Bed & Breakfast Application Page 10 APPLICABLE IN NEW JERSEY - NEW JERSEY FRAUD STATEMENT Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. APPLICABLE IN NEW MEXICO – NEW MEXICO FRAUD STATEMENT Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. APPLICABLE IN NEW YORK - NEW YORK FRAUD STATEMENT Other than Auto: 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 violation. Auto: Any person who knowingly makes or knowingly assists, abets, solicits, or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, 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 value of the subject motor vehicle or stated claim for each violation. APPLICABLE IN OHIO - OHIO FRAUD STATEMENT Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA – OKLAHOMA WARNING WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN OREGON – OREGON FRAUD STATEMENT 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 may subject the person to criminal and civil penalties. APPLICABLE IN PENNSYLVANIA – PENNSYLVANIA FRAUD STATEMENT 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. APPLICABLE IN TENNESSEE - TENNESSEE FRAUD STATEMENT It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. APPLICABLE IN UTAH - UTAH FRAUD STATEMENT For your protection, Utah law requires the following to appear on this form: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. APPLICABLE IN VERMONT – VERMONT FRAUD STATEMENT 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 may subject the person to criminal and civil penalties. APPLICABLE IN VIRGINIA – VIRGINIA FRAUD STATEMENT It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. APPLICABLE IN WASHINGTON – WASHINGTON FRAUD STATEMENT It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. APPLICABLE IN WEST VIRGINIA – WEST VIRGINIA FRAUD STATEMENT Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. GENERAL FRAUD STATEMENT ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OK, OR, or VT; in DC, LA, ME, TN, VA, and WA, insurance benefits may also be denied). THE UNDERSIGNED REPRESENTS THAT HE/SHE HAS MADE A GOOD FAITH EFFORT TO ASCERTAIN COMPLETE AND ACCURATE ANSWERS TO THE QUESTIONS SET FORTH IN THIS APPLICATION AND THAT THE INFORMATION PROVIDED IN THIS APPLICATION, INCLUDING ANY ATTACHMENTS, IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF THEIR KNOWLEDGE AND BELIEF. Applicant's Signature: Date: Name and title (please print): Insurance Broker’s Signature Edition 03/10 Date: AdvenSure Bed & Breakfast Application Page 11
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