Fillable Home Inspector Insurance Application Final

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Home Inspector Insurance Application Final

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WHI APP-29-141 (07-12) Page 1 of 6
Inspectors General and Professional Liability Application
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Please provide the following information along with this application:
1. Resume of all inspectors.
2. A copy of the pre-inspection agreement.
3. Copies of all training certification documents for each inspector.
4. Detailed information on all prior claims, including prior company loss runs.
5. A copy of your current Declarations Page sho
wing the current retroactive date, if applicable.
Company Name:
Company Address:
City: State: Zip:
Contact Name:
Contact Phone:
Business Phone: Business Fax:
E-mail:
Website Address:
Form of Business:
Individual Partnership Corporation
LLC Other:
Proposed Effective Date: Proposed Expiration Date:
Professional and General Liability Limits Desired:
$250,000 Occurrence/$250,000 Aggregate $500,000 Occurrence/$1,000,000 Aggregate
$250,000 Occurrence/$500,000 Aggregate $1,000,000 Occurrence/$1,000,000 Aggregate
$300,000 Occurrence/$300,000 Aggregate $1,000,000 Occurrence/$2,000,000 Aggregate
$500,000 Occurrence/$500,000 Aggregate $2,000,000 Occurrence/$2,000,000 Aggregate
The Professional Liability limit will match the ocurrence and aggregate limit ch
osen for General Liability. Separate limits
apply to each coverage.
Professional Liability Deductible Desired:
$1,000 $1,500 $2,000 $2,500 $5,000 $10,000
Note: There is no deductible applicable to the General Liability.
IMPORTANT NOTES: In order to make completion as easy as possible for you, this form is designed to be completed on your computer. Alternatively, you may print the blank form and
complete it manually. When using the onscreen option, you may save the form (completed or even partially completed) by choosing “SAVE AS” and renaming the document. This option will
retain all information entered. If you have the appropriate software, you may also choose “Print to PDF.” For more information, please visit www.Adobe.com.
Clear Form
To Submit: Save then email
to Inspectors@orep.org;
Fax to (708) 570-5786
(Required for quoting)
WHI APP-29-141 (07-12) Page 2 of 6
General Information
1. Is your firm a franchise? .............................................................................................................................. Yes No
If “yes,” please provide the following:
Franchise Name Address City State Zip
2. When was your firm established? *Please attach resume/summary of experience
3. Is the applicant owned or controlled by any other firm or individual? ..........................................................
Yes No
If yes, please explain:
4. Are any other services provided outside the scope of inspections? ...........................................................
Yes No
If yes, please explain:
5. Has the name of the appli cant been changed, or has the applicant merged with or acquired another
practice unit within the past five years?
.......................................................................................................
Yes No
If yes, please explain:
6. Please list all states that you provide inspections in:
Are you certified/licensed to inspect in these states? .................................................................................. Yes No
Operations
7. STAFF
NAME
TYPE
(O, E, IC)
FULL-TIME OR
PART-TIME
YEARS OF
EXPERIENCE
CERTIFIED
(YES/NO)
O=Owner, partner or officer E=Employed Inspector IC=Independent Contractor Inspector
(See independent contractor section below—coverage for independent contractors is not automatic).
8. If less than three years of experience as Home Inspector, do they have at least three years experience
in construction trade or in real estate? ........................................................................................................
Yes No
9. Do you belong to any professional organization? .......................................................................................
Yes No
(please check off applicable)
ASHI NACHI NAHI FABI CREIA
GAHI TAREI ITA AHIT HIIA
10. Revenues: $
Next year projection (Please include revenues of ICs if applicable)
$
Current year
$
Last year
11. Number of inspections performed annually:
(if this is a new venture, please provide an estimate)
*Questions #10 and #11 are REQUIRED FOR QUOTING and cannot be left blank.
*
*
WHI APP-29-141 (07-12) Page 3 of 6
12.
TYPE OF INSPECTIONS PERCENT OF TOTAL REVENUE
Residential Inspections %
 Commercial Inspections %
 RadRQ Inspections %
a. Do you perform remediation? ..................................................................................................... Yes No
b. Is the laboratory used EPA listed? ............................................................................................. Yes No
c. Radon Testing Equipment used?
Pool/Spa Inspections %
Septic Inspections %
Energy Audits Inspections %
WDWer Quality Testing
%
H8' Inspections %
a. Please describe the types of HUD inspections:
Lead Inspection (excluded—see optional coverage section) %
Termite Inspections (excluded—see optional coverage section) %
Mold Inspections (excluded—see optional coverage section) %
ConVWruction Draw Inspections %
a. Who are your clients?
b. Please provide a sample contract for this service.
Wind Mitigation Inspections %
Infrared Thermography (IR) Inspections %
4-Point,nspections %
Code Compliance Inspections %
a. Who are your clients?
b. What code is used?
ConVXlting Services %
a. Please provide a description of any consulting services performed.
13. What percentage of your revenues is derived from real estate referrals? ................................................... %
14. Does any client represent more than twenty-five percent (25%) of your annual revenue? ........................
Yes No
If yes, please explain:
15. Are you a remodeling/repair contractor or a building contractor? ...............................................................
Yes No
If yes, please explain:
If yes, do you have separate coverage in place? ........................................................................................
Yes No
Do you perform inspection on the same properties? ...................................................................................
Yes No
16. Are any inspectors degreed and/or professionally designated architects or engineers? ............................
Yes No
If yes, and currently practicing, is separate coverage in place? ..................................................................
Yes No
17. Do all inspectors take photographs? ........................................................................................................... Yes No
WHI APP-29-141 (07-12) Page 4 of 6
Independent Contractors
18. Do you utilize the services of independent contractors? ............................................................................. Yes No
If so, what percentage of your inspections is completed by independent contractors? ...............................
%
19. Do you require all independent contractors to carry and provide proof of insurance? ................................ Yes No
If no, independent contractors must have coverage. Please provide the names of all independent contractors that are
to be covered under this policy and provide copies of their resumes.
Use of Agreements and Contracts
20. Is the pre-inspection agreement/contract used one hundred percent (100%) of the time? ........................
Yes No
21. Do you offer any guarantees or warranties? ...............................................................................................
Yes No
If yes, please explain:
Claims & Disciplinary Actions
22. Has any inspector had their license revoked, subject to a
ny fine, criminal penalty, been subject to
disciplinary action by any state li
censing board, court, regulatory authority, or professional association
related to inspections? .................................................................................................................................
Yes No
If yes, please explain:
23. During the past five years, has any insurance company denie
d, cancelled, or non -renewed your pro-
fessional liability insurance? (not applicable to Missouri applicants) ..........................................................
Yes No
If yes, please explain:
24. Are you aware of any act, error, omission or other circumstances which might result in a claim being
made against you, your firm, any current or past partner, officer, owner or employee of the
applicant? ....................................................................................................................................................
Yes No
If yes, please provide details on the attached claim supplement form.
25. Have any claims or suits been brought again
st any member of the applicant, a predecessor, of
the ap plicant or any current or pa
st pa rtner,
officer, owner, or employee th ereof during the pa st five
years? ..........................................................................................................................................................
Yes No
If yes, please provide details on the attached claim supplement form.
Previous/Current Coverage
26. Please list the following information regarding inspectors professional liability insurance within the past five years (if
no prior insu
rance, please write
N/A).
INCEPTION
(MM/DD/YY)
EXPIRATION
(MM/DD/YY)
INSURANCE
COMPANY
PREMIUM LIMITS DEDUCTIBLE
$ $ $
$ $ $
$ $ $
Please provide a copy of your expiring Declaration page.
Is the applicant’s expiring policy issued on a Claims-Made basis? .............................................................
Yes No
If yes, please provide the Retroactive Date of the expiring policy: ...............................................................
WHI APP-29-141 (07-12) Page 5 of 6
27. Please list the following information regarding home inspectors General Liability insurance within the past five years (if
no prior insurance please write N/A).
INCEPTION
(MM/DD/YY)
EXPIRATION
(MM/DD/YY)
INSURANCE
COMPANY
PREMIUM LIMITS DEDUCTIBLE
$ $ $
$ $ $
$ $ $
Please provide a copy of your expiring Declaration page.
Optional Coverage
Please check off any optional coverage that is desired.
Termite Inspections
Estimated total revenue for the next twelve (12) months from this service: ............................................. $
Do you provide treatment? .......................................................................................................................... Yes No
If yes, please explain:
Please select limit desired:
$100,000/$100,000 $250,000/$250,000 $500,000/$500,000
Lead Inspections—$100,000/$100,000 limit
Estimated total revenue for the next twelve (12) months from this service: ............................................. $
Do you provide lead remediation or consulting services? ........................................................................... Yes No
Mold Inspections—$100,000/$100,000 limit
Estimated total revenue for the next twelve (12) months from this service: ............................................. $
Do you provide mold remediation or consulting services? .......................................................................... Yes No
Property Coverage (if checked, complete supplemental property application)
This appli
cation does not bind the applicant nor the Company to complete the insu
rance, but it is agreed that the informa-
tion contained herein shall be the basis
of the contract should a policy be issued.
NOTICE TO APPLICANT—PLEASE CAREFULLY READ THE FOLLOWING:
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim contai ning any materially false information or con ceals for the purpo se of
misleading, information concerning any fact mate rial ther eto commits a frau dulent i nsurance act, whi ch is a crime and
subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is u nlawful to kn owingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purp ose of defrau ding or attemptin g to defrau d the com pany. Penalties m ay
include imprisonment, fines, deni al of insu rance, and civ il dam ages. Any insurance compa ny or age nt of an in surance
company who knowingly provides false, incomplete, or misl eading facts or information to a policy h older or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING T O DIST RICT OF COLUMBIA APPLICANTS: It is a crime to p rovide fal se or mi sleading information to
an insurer for the purpo se of defrauding the insurer o r any ot her person. Penalties include imprisonment and/or fines. In
addition, an i nsurer may d eny insurance benefits if false info rmation materially related to a claim was provided by the
applicant.
WHI APP-29-141 (07-12) Page 6 of 6
NOTICE TO FLORIDA APPLICANTS: Any pe rson who knowingly and with intent to inj ure, defraud, or deceive any in-
surer files a statement of claim or an ap plication containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime a nd may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, inco mplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a d enial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false o r fraudulent claim for
payment of a loss or benefit or who kn owingly an d willfully presents fal se information in an application f or insurance is
guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO OHIO APPLI CANTS: Any person who knowingly and with intent to defra ud any insurance company files an
application for insurance or statement of claim contai ning any materially false information or con ceals for the purpo se of
misleading, information concerning any fact mate rial ther eto commits a frau dulent i nsurance act, whi ch is a crime and
subjects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and wit h intent to inj ure, defraud or deceive any
insurer, makes any claim for the proceeds of an in surance policy containing any false, incomplete or misleading informa-
tion is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (Applicable in Te nnessee, Virginia and Washington): It is a cri me to knowingly provide false, in-
complete or misleading information to an insurance company fo r the pu rpose of defraudi ng the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or statement of claim containing any mate rially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE:
DATE:
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
SUBMIT THIS APPLICATION TO:
Inspectors@orep.org or fax to (708)570-5786
click to sign
signature
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SUPPLEMENTAL CLAIM / INCIDENT INFORMATION
This form should be completed for each claim, suit or incident Applicant is aware of after inquiry of all
partners, officers, owners and employees.
Please ensure that all questions are answered completely.
1. Full name of Applicant or Insured:
2. Full name of Applicant who reported claim:
3. Full name of claimant:
4. Indicate whether:
Claim/suit Incident
5. Date of alleged error: / /
6. Date you became aware of alleged error: / /
7. Date it was reported to your insurance carrier: / /
Name of your insurance carrier:
8. Additional defendants:
9. a. IF CLAIM CLOSED indicate date closed: / /
Total amount paid $
b. Of the total amount paid, how much was paid for legal expenses: $
What was your deductible: $
10. IF PENDING, PLEASE SEND SUIT PAPERS AND ANSWER ALL QUESTIONS BELOW:
a. Claimant’s settlement demand $
b. Defendant’s offer for settlement $
c. Insurer’s loss reserve $
(Available by calling your insurance company and/or defense counsel)
d. Is claim in suit?
Yes No
If yes, amount asked in summons $
e. Limits of liability
Deductible
11. Name of insurance carrier responding to this claim or incident:
12. Provide a brief description of the claim, indicating the alleged error, type of engagement and alleged
injury.
Signature of Owner, Officer or Partner Date (month-day-year)
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Home Inspector Insurance Application Final

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Completed 18 July 2020

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