Sweeten Your Insurance Program

  • ACE National designates RMS a Premier ACE Member Industry provider
  • ACE Members now receive the exclusive 5% insurance discount on flexible coverage forms
  • RMS is not just another insurance agent, rather we are a managing general agent (MGA) with the pen to allow us quote policies “in-house”
Complete the application below to begin the process of reducing your insurance costs!

ACE National Member Exclusive Discounted Insurance Program

General Information


Prior Coverage Information

CoverageYear (dd/mm/yyyy)Prior CarrierPrior Premiums
Liability
Liquor
Excess

Please Select the Coverages Desired

Excess Liability Coverage

Operational Survey (All Locations)

Hours of Operations

Day of weekOpenClose
Monday
Thursday
Wednesday
Thursday
Friday
Saturday
Sunday

Parking Operations

Receipts

Proposed Term

(For Proposed Term)

Expiring Term

(For Prior 12 Months)

Rental / Catering

Entertainment

Other Business Locations

Operations


Drop a file here or click to upload Choose File
Maximum upload size: 516MB

Fire Safety

Security

Number of security per:

Additional Insured

Please list any other entities Member is requesting to be added as Additional Insured


FRAUD STATEMENT: Any person who knowingly and with the 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.

The Member hereby certifies, based upon reasonable and diligent investigation and to the best of the knowledge of the Member, its owners, officers, employees and representatives, that with respect to the insured operation(s) and location(s) for which this application is being submitted:

Preliminary Claims History


WARRANT: THE UNDERSIGNED REPRESENTS AND WARRANTS, TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, BASED ON REASONABLE INQUIRY, THAT THE PARTICULARS AND STATEMENTS SET FORTH ON THIS APPLICATION ARE TRUE, CORRECT AND ENTIRELY COMPLETE, AND THERE ARE NO OTHER RISK FACTORS THAT HAVE NOT BEEN DISCLOSED HEREIN. IF ANY PARTICULARS OR STATEMENTS ARE MATERIALLY MISREPRESENTED OR MATERIAL INFORMATION HAS BEEN OMITTED INTENTIONALLY OR ACCIDENTALLY, SUCH MISREPRESENTATION OR OMISSION WILL VOID ANY ISSUED COVERAGES AND THE INSURANCE COMPANY WILL HAVE NO DUTY TO DEFEND ANY CLAIMS, PAY ANY DAMAGES, OR PAY SUMS OR PERFORM ACTS OR SERVICES. THE UNDERSIGNED AGREES AND ACKNOWLEDGES THAT THE PARTICULARS AND STATEMENTS SET FORTH HEREIN ARE MATERIAL TO THE ACCEPTANCE OF THE RISK ASSUMED BY THE INSURANCE COMPANY AND THAT THE INSURANCE COMPANY IS RELYING UPON THE TRUTH AND COMPLETENESS OF THE RISK FACTORS DISCLOSED HEREIN. IT IS AGREED BY THE UNDERSIGNED THAT THIS APPLICATION, INCLUDING ANY MATERIAL SUBMITTED HEREWITH, SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND THIS APPLICATION SHALL BE ATTACHED TO AND BECOME A PART OF THE POLICY. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE MEMBER WILL NOTIFY THE UNDERWRITER IMMEDIATELY IN WRITING AND THE UNDERWRITER MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION OR PROPOSAL.

Signature of Member (Must be Owner, Officer, or Partner)

Location Survey

Location
DBA
Street, City, State, ZipSquare
Footage
Building
Coverage
Amount (or N/A)
Contents
Coverage
Amount
Hours of
Operation

All fields marked with (*) are required.


Please check "I'm not a robot" to verify you are human.
Sending

Contact RMS HG to find out more about partnering on hospitality program insurance for your accounts. We are just a click or phone call away!
Give us a call at 516.742.8585, ext. 204.