Heritage Bed & Breakfast Insurance

BASIC INFORMATION

Trade name of inn:

Named insured (Individuals):

Named insured (Corporate name):

Named insured (Building owners):

Mailing address:

Street address:

City:

State:

Zip:

Phone Number with Area Code:

Web page address:

* Email address:

Contact name at inn:

Entity:

Individual

LLC

Joint Venture

Partnership

Corporation

Does the named insured (individual) reside at an insured premise?

Yes

Is the named insured involved in any other business?

Yes

If yes give details:

BUILDING INFORMATION (Additional copies if needed)

Inn name:

Premise number:

Building number:

Number of stories:

Square Footage:

Year built:

Construction:

Building occupancy:

Building limit of insurance ($):

Contents Limit of Insurance:

Sprinklered building:

Yes

Floors with guestrooms (all that apply):

1st Floor

2nd Floor

3rd Floor

4th Floor

FOR HABITATIONAL BUILDING, COMPLETE THE FOLLOWING SECTION

Does an innkeeper live on or near the premises?

Yes

If No to the above, (check) applicable life safety measures below that are in place:

Smoked alarms hard wired to a fire department either directly of via a central station with under a 5 minute response time to premise:

Smoke alarms hard wired to an outside siren audible by the Innkeeper/manager:

Direct means of egress from each 1st floor bedroom via a window or a door:

Direct means of egress from each 2nd floor bedroom via a window or door to a balcony or fire escape:

Is there a second means of egress for 3rd or 4th floor guestrooms?

	Improvements		Improvement Dates	Certified by Licensed Contractor
Heating	Yes	No		Yes	No
Wiring	Yes	No		Yes	No
Roof	Yes	No		Yes	No
Plumbing	Yes	No		Yes	No

MORTGAGEE INFORMATION

CURRENT POLICY

Effective Date:

Expiration Date:

Company Name:

Fine Arts & Antiques:

Yes

Work Comp:

Yes

Flood:

Yes

Umbrella Liability:

Yes

If Yes, Umbrella Liability Limit:

Deductible:

$250

$500

$1,000

LOSS PAYEES AND ADDITIONAL INSUREDS INFORMATION

UNDERWRITING INFORMATION

If coastal location, distance to ocean (mi):

Date current operations started(mm/dd/yy):

Number of employees:

Breakfast provided:

Yes

Boiler inspection required:

Yes

Types of operation:

B & B

Restaurant

Catering

Gift Shop

Other

Is premises occupied year round:

Yes

If no, are buildings winterized:

Yes

Is the inn operational year round:

Yes

If no, length of operations during the course of a year (months):

Type of fire station:

Manned

Volunteer

Distance to fire station:

Other forms of fire control:

Pool

Pond/Lake

Other

Closest fire hydrant:

If yes to pool, pond/lake, is there a diving board?

Yes

number of guest rooms in all buildings:

Number of long term rentals:

Are there smoke alarms in all bedrooms and corridors?

Yes

If yes, type of connection used to power smoke alarm:

Are temporary space heaters used?

Yes

If yes, type of heat source:

Automatic emergency lighting in each guest room (battery or wired):

Yes

Is there any operable knob & tube or aluminum wiring?

Yes

Are wood burning fireplaces/stoves used?

Yes

If yes, are all chimneys & flues cleaned annually?

Yes

VALUES OF INSURANCE

Value of scheduled items:

Jewels
$

Furs
$

Fine Art
$

Number of guest rooms:

Restaurant receipts ($):

Liquor receipts ($):

Other receipts ($):

Total receipts ($):

Explain other:

CURRENT POLICY

Any claims in the last five years?

Yes

If yes explain:

Carrier:

Expiration date:

Has prior insurance been:

Declined

Canceled

Non-renewed

Explain:

ADDITIONAL ACTIVITIES

Bicycles provided to guest(s)?

Yes

If yes, are helmets provided?

Yes

Is a wavered signed?

Yes

Boats available to guest(s)?

Yes

If yes, is a waiver signed?

Yes

Cross Country skis provided to guests?

Yes

If yes, are helmets provided?

Yes

Is a waiver signed?

Yes

Are any of the above amenities offered to the public (non-guests)?

Yes

PREMISE INFORMATION

List all premises owned, rented, or leased:
Street address:
City:
State:
Zip:
Number of buildings:
Description:
Country:
Street address:
City:
State:
Zip:
Number of buildings:
Description:
Country:
Street address:
City:
State:
Zip:
Number of buildings
Description:
Country:

* = Required

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Thank you for your information we will be in touch with you if we need any additional information.