B+B Resorts App Bed Rider 822 Adven Sure BBResorts
User Manual: Bed Rider 822
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Page Count: 11
Edition 03/10 AdvenSure
Bed & Breakfast Application Page 1
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: _ E-mail address: ___________________ __
Do you currently write this account? Yes No
If yes, for how long? _________________ Carrier Name? _______________________________
Is the account Sub-Brokered? Yes 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 Other
Years in operation: (Minimum Requirement: 3 Years in Operation)
Total # of Guides/Outfitters: 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? Yes No
If so please provide details:
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? Yes No
If yes, please provide dates, coverage and explanation:
Are you a member of any state or regional association? Yes No
If yes, please list:
B
ED & BREAKFAST/RESORTS APPLICATION
P.O. Box 5670
Cortland, NY 13045
Phone: (800) 822-3747
Fax: (607) 756-5051
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Bed & Breakfast Application Page 2
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
If yes, list location numbers:
Do any buildings have any ACTIVE Knob & Tube and/or Aluminum wiring? Yes No
If yes, list location numbers:
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
If yes, is there a formal maintenance contract in place? Yes No
Do you have fire extinguishers readily available? Yes No
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
Does the water around your dock freeze? Yes No
Are the docks removed? Yes No
Edition 03/10 AdvenSure
Bed & Breakfast Application Page 3
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
(claims made only)
$1 million/$2 million $1 million/$3 million
Retroactive Date:
**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
If no, provide the number of months you are open?
Do you or a manager live on the premise? Yes No
If yes, is there separate homeowners or tenants coverage in place? Yes No
If no, please complete the Personal Liability Supplement.
Is staff on premise while guests are present? Yes No
If no, are guests provided with emergency contact information? Yes No
Do you have any dogs on the premise (other than those owned by your guests)? Yes No
If yes: What breed(s)?
Are your dogs ever allowed into guest areas or around guests? 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? Yes No
If yes, please complete and attach the Liquor Supplement.
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Bed & Breakfast Application Page 4
SUBCONTRACTOR INFORMATION
Does the organization hire subcontractors? Yes No
If yes, are certificates of insurance obtained from all subcontractors? 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? Yes No
Activities Conducted Guided Revenue
ATV/Snowmobile Operations (complete section below) $
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
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Bed & Breakfast Application Page 5
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 Other:
Conveyance Type: Tractor Horse Other:
Rides take place on: Public Roads Public Areas Private Land (your premise)
Maximum Number of Passengers:
Are rides operated and/or supervised by employees? 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
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
If yes, is the pony hand led? Yes No
What is the youngest rider you will allow on a pony? years old
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
If yes, do you allow your guests to participate? Yes No
Do you conduct cattle drives? Yes No
If yes, what is the wrangler to rider ratio? /
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
List any reasons why you would decline a person from riding (health, age, alcohol, etc).
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Bed & Breakfast Application Page 6
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
What percentages of tours are: Off-road: % On-road: %
POOL & SWIMMING AREAS
How many of each: Pools Lakes/Ponds Other: please specify:
Are your swimming facilities open to the general public? Yes No
Are pool areas fenced? Yes No
If yes, does it have a childproof, self-locking gate? 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
If no, is there a sign indicating “No lifeguard, swim at your own risk, no diving”? 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
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? Yes No
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 7
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
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? Yes No
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? Yes No
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 Boat Bus/Vehicle Hiking Horses Other:
What is the tour guide to guest ratio? /
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Bed & Breakfast Application Page 8
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**
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Bed & Breakfast Application Page 9
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): $
(current year)
Carrier(s): $
(1st prior year)
Carrier(s): $
(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
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Bed & Breakfast Application Page 10
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.
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Bed & Breakfast Application Page 11
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 Date:
