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Location: Home >> Programs >> Hotel/Motel >> R66 Application
 
Hotel/Motel Program R-66 Application
Hotel Motel Program Supplemental Application


General Information
Customer Code: 
Ownership Name: 
Mailing Address: 
City:  State:  Zip: 
Contact Person:  Phone: 
Contact Email: 
Effective Date:  Mobile:  Fax: 
 
Coverage Requested:  Package     Automobile     Liquor     Restaurant 


Location Information
Location#:  # of Bldgs:  Prop ID Num:  QA Score: 
Number Units:  Location Telephone: 
Location Manager: 
Location Name: 
Street:  City: 
County:  State:  Zip: 
Building Value:  $ Contents:  $ Grs Income:  $  
Annual Rm Rental:  $
Year Built:  # Stories:  Bldg Const:  Roof: 
Square Footage:  Circ Breakers:  Wiring Type: 
Occupancy: %
  Hotel
  Restaurant
  Convention
  Ext Stay
Sprinklered: %
  Full
  Partial
  None
Life Safety:
  Peep Holes
  Smoke Detectors
  Fire Extinguishers
  Internal Safety Lock
Pool:
  Self Closing doors
  # Indoor
  # Outdoor
  5' Fencing
  Depth Markers
Building Updates: 
Crime, Money and Security Exposure:
Cash  $  Checks  $  CC Receipts 
Number of employees who handle money or securities? 
Safe on Premises? 
 
Do employees who reconcile the bank statement also:
Make deposits  Make withdrawals  Sign checks 

Additional Comments: 

All questions must be complete. Quote is subject to receipt of company loss runs and photos. Coverage is subject to on-site inspection, policy provisions, exclusions, conditions and deductibles.

Agent / Broker Information:
  Name     Street  
  Agency     City/St/Zip  
  Phone     Email  
  Fax    
 


By clicking the Submit Form button, you agree that the information
provided is true and correct to the best of your knowledge.

     

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