Hotel - Motel Businesssowners Insurance Quote Request

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Hotel / Motel Owners Insurance Quote Request Form

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured:

General Information:

* Business Name

Type of Business :

*Contract - Full Name:

Describe Operations :

* Title / Position:

Business Model:

* Employers Federal Tax Id # (FEIN)

Select Any Other Kinds Of Coverage Below That You Need Quoted:

*Contact Phone:

Cell #

Building / Contents / Liability

Business Owners Policy :

Flood Insurance :

Workers Comp: Fidelity/Surety Bond

*Fax:

Commercial Auto: Cargo / Freight

Heavy Equipment Cargo ( Inland/Ocean)

Web Site Address:

Umbrella Liability: Professional Liability :

Other - Please specify or describe:

*Email:

*Send Quick Quote By : Email Fax Both

Current Insurance Carriers Name :

Policy Number

Expiration Date:

OccurrenceClaims Made

If Claim Made Provide Retroactive Date:

Please send copy to : edhemhill@hemphillinsuranceagency.com or Fax (936) 448-1013

*Business Address:

Address:

City:

State: Zip :

County:

Mailing Address: Same as Mailing Address
Address:

City :

State: Zip:

County :

Business Information:

Years in Business:		Total Number of Employees:	Employees : # Full Time: # Part Time:
Approx. Annual Gross Sales / Revenue $		Approx. Annual Payroll $

Commercial Property Coverage Limits Requested:
*Replacement Cost Coverage	Building (Structure) Business Personal Property (Contents)	*Requested Effective Date:
* Building Coverage Limit $		*Business Contents Property Limit $
*Deductible $		*Wind/Hail Deductible$
Property of Others $		Computer Equipment $
Mechanical Breakdown (Ac/Heater/Boiler/Machinery)		Computer Software $
Off Premises Coverage $		Building Glass $
Business Interruption Coverage $		Extra Expense Coverage $
Sign Coverage $		Money & Securities Coverage $
Ordinance or Law Coverage $		Accounts Receivable Coverage $
Spoilage Coverage $ (Perishable goods)		Valuable Papers Coverage $
Utility Services - Direct Damage $		Utility Services - Time Element Coverage $
Backup of Sewer $		Law Library $
General Liability Coverage Limits Requested: Select Policy Type: Occurrence Claims Made
*General Liability Limit $ Per Occurrence Combined Single Limit	Limit Per Each Occurrence Aggregate Limit All Claims	Product or Complete Operations Coverage $
* Medical Expense (No Fault) $		Personal & Advertising Injury $
* Deductible $ Per Claim Per Occurrence		Employee Benefits Liability $
*Fire Legal Liability $		Garage keeps Coverage $
Host Liquor or Liquor Liability $		Hired or Non-Owned Auto Liability $
Does you business currently have Professional Liability Insurance Coverage?YesNo If " Yes" Provide Insurers Name Policy # Effective Date

Locations: Check Here If You Have More Than 1 Location ( We will be contacting you by telephone or email to get additional location information )

Location	Street	City	State	Zip Code	County	Bldg Square Feet	Number Of Employees

Interest	Owner Tenant	Year Built		% Occupied

Occupancy Information:

Location	Click To View Building Construction Type	Year Building Constructed	Number Stories	Distance To Fire Hydrant	Distance To Fire Station	Inside City Limits
						Yeno

Location	Fire Alarm Type	Does the business have a Fire Alarm Certificate?	Number Of Employees At This Location	Ownership - Mortgaged ?	Annual Rental Revenues (If applicable)	Percentage of Building Occupied
		YeNo			$	%
Does anyone permanently reside at any location ? YeNo If "Yes" List Locations
Location	Burglar Alarm Type	Does the business have a Burglar Alarm Certificate?	Number Of Basement Levels	Does building have fire sprinklers?	If sprinklers what % of building has sprinklers?	Square Footage Occupied By Your Business
		Yes No		Yes No	%	Sq Ft
Normal number of hours per day your business operations
Location	Indicate by checking the appropriate box below if any of the safety/security measures listed have been implemented :
	Exterior Light Front/Back Exterior Doors 2Cylinder Dead-Bolt Doors Wire Mesh/Bars Guard DogGuardVideoSmoke DetectorHoldup AlarmSafe
What is the maximum amount of cash money left at any location overnight ? $
Swimming Pool located on premises ? Yes No If "Yes" : Pool completely fenced within 4ft+ fence with self locking gates ? Yes No If " Yes" : Life Guard On Duty During Posted Pool Hours ? Yes No Are Pool Use and Safety Rules Prominently Posted At Pool Side ? Yes No
Restaurant(s) located on premises ? Yes No
Does Your Restaurant(s) Operate With Vented Hood Cooking Exhaust Systems? Yes No If "Yes " Answer The Following Questions: Restaurant(s) Operates With Underwriters Laboratory (UL) Rated Automatic Fire Extinguishing Systems ? Yes No Manufactures Name Model Yr. Manufactured UL Rating If " Yes " Date Last Serviced Date Last Inspected Type System Dry Wet
Bar / Tavern located on premises ? Yes No

Loss History Information:

Our Insurance Company Underwriters May Require Prior Carrier Generated Loss History Reports For Last 5 Years Prior To Binding Coverage.

*Has your business had any losses or filed a claim in the last five (5) years? YesNo

If "Yes" Please Provide Full Details ( amount paid / carrier / policy # / date of loss or claim / nature of claim / pending or settled)

Underwriting Questions & Information:

Please carefully review the questions and pre-selected answers below. Please make any corrections necessary so as to assure that each question presented herein has been correctly and truthfully answered to the best of your knowledge.

ACORD 125 PAGE 2 Questions 1a through 12.	ACORD 126 PAGE 3-4 Questions 13. through 20.
1a.Is the applicant a subsidiary of another entity ?YesNo	13. Any demolition exposure contemplated ? YesNo
1b.Does the applicant have any subsidiaries ? YesNo	14. Has applicant been active in or is currently active in joint ventures? YesNo
2. Is a formal safety program in operation?YesNo Most Insurance Companies require any insured business owners to provide written proof at time of application and at each annual renewal that their firm maintains a written safety manual and documentation that the your firm conducts weekly employee safety meeting. Click Here To Get Affordable Safety Program	15. Do you lease employees to or from other employers ? YesNo
3. Any exposure to flammables , explosives, chemicals ? YesNo	16. Is there a labor interchange with any other business or subsidiaries ? YesNo
4. Any catastrophe exposure ? YesNo	17. Are day care facilities operated or controlled ? Have any crimes occurred or been attempted on your premises within the last three (3) years ? YesNo
5. Any other insurance with this company or being submitted ? YesNo	18. Have any crimes occurred or been attempted on your premises within the last three (3) years ? YesNo
6. Any policy or coverage declined, cancelled, or non-renewed during the prior 3 years? YesNo	19. Is there a formal, written safety and security policy in effect ? YesNo Most Insurance Companies require any insured business owners to provide written proof at time of application and at each annual renewal that their firm maintains a written safety manual and documentation that the your firm conducts weekly employee safety meeting. Click Here To Get An Affordable Safety Program For Your Business
7. Any past losses or claims related to sexual abuse or molestation allegations, discrimination or negligent hiring ? YesNo	20. Does the business promotional literature make any representations about safety or security of the premises ? YesNo
8. During last 5 yrs has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property ? YesNo	ACORD 126 PAGE 2 - Contractor Questions 1. through 6. Complete This Section Only If You Firms Operates As A Contractor Check If You Are A Contractor
9. Any uncorrected fire code violations ? YesNo	1. Does applicant draw plans, design, or specification for other ? YesNo
10. Any tax liens, law suits, or bankruptcy within 5 years?YesNo	2. Do any operations include blasting or utilize or store explosive material ? YesNo
11. Has business been placed in a trust ? YesNo	3. Do any operations include excavation, tunneling, underground work or earth moving ? YesNo
12. Any foreign operations, foreign products distributed in USA, or US products sold/distributed in foreign countries ? YesNo	4. Do your sub-contractors carry coverages or limits less than yours ? YesNo
ACORD 126 PAGE 3-4 Questions 1. through 12.	5. Are sub-contractors allowed to work without providing you with a certificate of insurance?YesNo
1. Any medical facilities provided or medical professionals employed or contracted ? YesNo	6. Does applicant lease equipment to other with or without operators ? YesNo
2. Any exposure to radioactive/nuclear materials? YesNo	Describe The Type Work Sub-contracted :
3. Do/Have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material ? YesNo (e.g. landfills, wastes, fuel tanks, ect )	Subs Paid Annually % Work Sub # Full Time # Part Time
4. Any operations sold, acquired, or discontinued in last five (5) years ? YesNo	ACORD 126 PAGE 2 - Products/Completed Operations Questions 1. through 10. If You Firms Is Requesting Products or Completed Operations Coverage Check Here & Complete This Section Only
5. Machinery or equipment loaned or rented to others ? YesNo	1. Does applicant install, service, or demonstrate products ? Yes No
6. Any watercraft, docks, floats owned, hired or leased ? YesNo	2. Foreign products sold, distributed, used as components ? Yes No
7. Any parking facilities owned/rented ? YesNo	3. Research and development conducted or new products planned ? Yes No
9. Recreation facilities provided ? YesNo	4. Guarantees, Warranties, Hold Harmless Agreements? Yes No If " Yes " Please explain in below remarks / comments section
10. Is there a swimming pool on the premises ? YesNo	5. Products related to Aircraft / Space Industry ? Yes No
10. Is there a swimming pool on the premises ? YesNo	6. Products recalled, discontinued, changed ? Yes N
11. Sporting or social events sponsored ? YesNo	7. Products of others sold ore re-packaged under applicant name ? Yes N
11. Sporting or social events sponsored ? YesNo	8. Products under label of others ? Yes N
12. Any structural alterations contemplated ? YesNo	9. Vendors Coverage Required ? Yes N
12. Any structural alterations contemplated ? YesNo	10. Does any named insured sell to other named insured's ? Yes N

Comments/Remarks

If you answered " Yes " above questions - please indicate question # with details ?

Additional Comments/Remarks You Wish Us To Consider While Preparing Your Quote:

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or current policy revisions you must receive a written confirmation for any new or change in coverage from our agency staff.

ACORD FILLABLE APPLICATIONS (These Are Insurance Industry Standardized Underwriting Forms Accepted By Virtually All Carriers )
#	Name	Description	Fillable Click
1.	ACORD 125	Commercial General Insurance Application
2.	ACORD 126	Commercial General Liability Section
2.	ACORD 140	Commercial Property Section


Download All Application Forms To Your System - Complete Applicable Fillable Application - Print Send To : Email edhemphill@hemphillinsuranceagency.com or Fax (936) 448-1013