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.

Step #1 — Home Inspector Information indicates a required field
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 Company Name of Applicant:
(Full Business Name)
Business Type:
Year Business Established:
Principal First Name:
Principal Last Name:
Business Street Address Line 1:
Business Street Address Line 2:
City:
State:
County:
Zip Code:
Is your mailing address the same as your business address above?

Mailing Street Address Line 1:

Mailing Street Address Line 2:

Mailing City:

Mailing State:

Mailing 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 Date 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
Do you use sub/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?

Please provide 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:
Additional Defense Costs?
(Additional costs up to 15%)
Deductible:

Optional Coverages

General Liability:
Pool or Spa Inspection:

Are you licensed or certified?

By whom?

Rodent Inspection:

Are you licensed or certified?

By whom?

Infrared Thermography Inspection:

Are you licensed or certified?

By whom?

Indoor Air Quality Inspection:

Are you licensed or certified?

By whom?

Mold Inspection:

Are you licensed or certified?

By whom?

Septic or Water Testing Inspection:

Are you licensed or certified?

By whom?

Lead Paint Inspection:

Are you licensed or certified?

By whom?

Exterior Insulation Finishing System and Stucco Inspection:

Are you licensed or certified?

By whom?

Green Building Inspection:

Are you licensed or certified?

By whom?

Radon Inspection:

Are you licensed or certified?

By whom?

Termite and Wood Destroying Insects Inspection:

Are you licensed or certified?

By whom?

Tank Sweep Inspection:

Are you licensed or certified?

By whom?

Pesticide Applicator:

Are you licensed or certified?

By whom?

Does any ONE of the services above represent more than 25% of your revenue?
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?

InterNACHI Member ID:

All InterNACHI members must apply through InterNACHI. Please click here to login and apply »

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 or any of your inspectors had professional liability or similar coverage cancelled, declined, or non-renewed?

Please provide details:

Are you currently covered by another E&O/Professional Liability insurance policy?

Current carrier:

Current policy expiration date:

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

Insurance Type Insurance Company Expiration Date Limit of Liability Deductible Premium (inc. taxes + fees)
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
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:

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?
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:

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

Pending or closed:

Covered by insurance?

Full name of individual(s) and firm involved in claim, suit or incident

Additional defendants

Name of claimant(s) or potential claimant(s)

Type of claim

Date of alleged error:

Date you became aware of error:

Date reported to carrier:

Name of carrier

Description of loss:

Description of your actions and liability to the claimant

What actions have been taken to prevent future similar losses?

Claim #2

Pending or closed:

Covered by insurance?

Full name of individual(s) and firm involved in claim, suit or incident

Additional defendants

Name of claimant(s) or potential claimant(s)

Type of claim

Date of alleged error:

Date you became aware of error:

Date reported to carrier:

Name of carrier

Description of loss:

Description of your actions and liability to the claimant

What actions have been taken to prevent future similar losses?

Claim #3

Pending or closed:

Covered by insurance?

Full name of individual(s) and firm involved in claim, suit or incident

Additional defendants

Name of claimant(s) or potential claimant(s)

Type of claim

Date of alleged error:

Date you became aware of error:

Date reported to carrier:

Name of carrier

Description of loss:

Description of your actions and liability to the claimant

What actions have been taken to prevent future similar losses?

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:
Additional Quote Options:



Workers Compensation

Federal Employer Identification Number (FEIN):

Number of employees and annual payroll broken down by class:
For example “4 home inspectors with combined 200K of annual payroll.” Same for office staff if applicable.

Will you as the owner participate? Your annual payroll/salary?

How do you inspect roofs? If you walk, are there any safety mechanisms in place to prevent falling?

Spam Protection:
The ____ fairy leaves money under your pillow.

loading...

You will be receiving your quote via email. Please add “elitemga.com” to your email whitelist.

Menu