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Home Inspectors E&O Application

Application must be completed in full in order to obtain a quote from the Elite InspectInsure Program. If a policy is issued, this application will attach to and become part of the policy, therefore, it is important all questions are answered accurately.

indicates a required field

Step #1 — Home Inspector Information
Are you an insurance agent applying on behalf of your client?

Agency Name:

Agency Address:

Agency City:

Agency State:

Agency Zip Code:

Agency Phone:

Agency Email Address:

Agency Contact Name:

Full Legal Name of Applicant:
(Full Business Name)
Year Business Established:
Principal First Name:
Principal Last Name:
Business Street Address Line 1:
Business Street Address Line 2:
P.O. Box:
City:
State:
County:
Zip Code:
Phone Number:
Cell Number:
Email Address:
Web Site Address:
Are there any other locations?

Please provide address:

Is the Applicant a franchisee?

Please provide full legal name of franchisor:

List all states in which the owner does business:

During the past 5 years has the name or ownership of the applicant changed or has there been an acquisition, merger, consolidation or other changes?


Please provide details:

Is the applicant owned by, controlled by or affiliated by any other entity or does the applicant own or control any other firm?


Please provide details:

Do you have any subsidiaries for which coverage is requested?


Please complete the schedule below:

Name % Owned Year Started Desc of Operations Entity Type

IMPORTANT: It is understood and agreed that coverage is not provided for subsidiaries unless the information requested above is provided.

Step #2 — Coverage Information
Effective Date Requested:

Please complete the following information for the current year:

  Full Time Part Time
Home Inspectors
Non-professionals

For Independent Contractors: Please provide the following additional information for each Independent Contractor

Name Does inspector work exclusively for the applicant firm? How many hours per week does the inspector work for the applicant firm? Does inspector have professional liability insurance coverage with limits the same as or higher than applicant carries?
Are all home inspectors licensed?

Have you, your company, or staff ever had your license revoked, suspended or been formerly reprimanded, or been the subject of a disciplinary action?

Details:

Does the applicant or any inspectors hold other professional licenses?

What license?

Estimated Annual Revenue

Current Year Most Recently Completed Fiscal Year
Income # Insp. Income # Insp.
Residential 1–4 units $ $
Residential over 4 units $ $
Commercial $ $
Other $ $

Breakdown of annual income from the following sources: (percentage)

Individual Seller / Prospective Buyer / Real Estate Agency: %
Lender / Mortgage Company / Mortgage Broker: %
Developer / Investor / Syndicator / Relocation Company: %
Other: %
Does any single client represent more than 25% of the Applicant’s gross annual revenue?

Please provide details:

Is the Applicant the exclusive inspector for any real estate agency, developer, and/or builder?

Please provide details:

E&O Liability Limit Requested:



Deductible:


Pool & Spa Inspection Liability?

Are you licensed or certified?


By whom?

Septic or Water Testing Liability?

Are you licensed or certified?


By whom?

Lead Paint Inspection Liability?

Are you licensed or certified?


By whom?

Premises General Liability?
(Property Damage and Bodily Injury)

Are you licensed or certified?


By whom?

Radon Inspection Liability?

Are you licensed or certified?


By whom?

Termite / WDI Liability?

Are you licensed or certified?


By whom?

Does the Applicant’s current policy have any endorsements or exclusions or coverage limitations tailored specifically to the Applicant?

Please describe endorsements:

Is there a pre-inspection agreement signed
prior to each inspection?

This program mandates that a pre-inspection/inspection agreement be used/signed for every inspection. Failure to do so with every inspection would disqualify you from the program/negate coverage.

Indicate type of inspection report used:

Type of Computer Software used to
Generate Reports:
Are pictures included on all reports?

Please provide details:

What Professional Associations
are you a member of?





If none, do you participate in a formal risk management or continuing education program?

What program?

What inspection standards / SOP is used?
Step #3 — Professional Liability Insurance History
During the past 5 years, have you are any of your inspectors had professional liability or similar coverage cancelled, declined, or non-renewed?

Please provide details:

Is your firm currently insured for professional liability?

Current carrier:

Current policy expiration date:

Does your current policy have a prior acts limitation or retroactive date?

Retro date:

Or…

Inception date of firm’s first claims made policy, maintained without interruption to date:
Has the Applicant ever purchased an Extending Reporting Period under any Professional Liability insurance policy?

Please provide details:

Please provide the following information regarding the Applicant’s most recent insurance policies:

Insurance Company Expiration Date Limit of Liability Deductible Premium
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Step #4 — Claim History
Within the past 5 years has the Applicant given notice of any claim, circumstance or potential claim to any insurer under any insurance coverage referred to above?
Has any person or entity proposed for this insurance been the subject of any professional liability claims during the past five years?
How many claims?

Claim #1

Open or closed:

Covered by insurance?

Date of inspection:

Date claims report:

Description of loss:

Amount Paid Indemnity:

Amount Paid Defense:

What actions have been taken to prevent future similar losses?

Claim #2

Open or closed:

Covered by insurance?

Date of inspection:

Date claims report:

Description of loss:

Amount Paid Indemnity:

Amount Paid Defense:

What actions have been taken to prevent future similar losses?

Claim #3

Open or closed:

Covered by insurance?

Date of inspection:

Date claims report:

Description of loss:

Amount Paid Indemnity:

Amount Paid Defense:

What actions have been taken to prevent future similar losses?

Does any person or entity proposed for insurance have knowledge of any act, error or omission that occurred within the past 5 years which might give rise to a claim(s) under the proposed policy?

Please indicate how many and describe:

Step #5 — Other
How did you hear about us?

Additional information that might be helpful in quoting/writing your professional liability insurance:

Digital Signature:
(print name)
Date:
Spam Protection:
What is H2O?

Fraud Warning Statements Click here to download PDF

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