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L362 (905) Page 1 of 6

By Marilyn Murray,2014-05-06 06:09
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L362 (905) Page 1 of 6

    HI001 (8/06) Page 1 of 6

    APPLICATION FOR INSPECTION SERVICES ERRORS & OMISSIONS INSURANCEAPPLICATION

    INSURANCE THE COVERAGE AFFORDED BY A POLICY, IF ISSUED, WILL BE ON A “CLAIMS MADE”

    BASIS.

    PLEASE FULLY COMPLETE EACH QUESTION, CIRCLE THE CORRECT RESPONSE WHEN A QUESTION

    ASKS “YES” OR “NO” AND ATTACH ADDITIONAL INFORMATION IFREQUIRED. PLEASE ALSO ATTACH:

1. Applicant Information:

Name of Applicant:

    Contact Person:

    Street Address:

    City County State, Zip:

    Telephone Number: Facsimile Number:

    Website Address: E-mail address:

Year Established:

Form of Business (circle one): Individual Partnership Corporation LLC Other (explain)

2. Please list addresses of all branch offices:

    A)

    B)

    C)

    3. Is the Applicant or any other proposed insured:

a) Owned by, controlled by or act as a Director or Officer of any other business or organization? YES/NO

b) engaged in any other business or employed by any other business or organization? YES/NO

    If YES, please explain:

    ________________________________________________________________________________________

________________________________________________________________________________________

If YES, what percentage of inspection services are performed for such business(s)? ___________________%

4. In the past FIVE years has the name of the Applicant been changed or has any other business been

    purchased, merged or consolidated with the Applicant? YES/NO

    If YES, please explain:

    ________________________________________________________________________________________

________________________________________________________________________________________

    (Must be signed by an Owner, Partner or Senior Officer)

HI001 (8/06) Page 2 of 6

5. Please detail the number of partners and staff:

     Full Time Part Time

    Principals/Partners /Inspectors):

    Professional Staff /Inspectors):

    Other Employees:

    TOTAL

6. Please detail the following for all owners, officers, directors, partners and professional employees:

    Attach a separate sheet if necessary

    Name % of ownership Professional Years of Years with (must total 100%) Qualifications experience applicant

7. Please detail annual gross income: Estimate for

Next year (20 ): _______________________ This year (20 ): _______________________

Last Year (20 ): _______________________

    8. What was the Applicant’s largest fee for an individual inspection job ever done?__________________________

What type of inspection was it?________________________

What is your average fee?___________________

9. How many inspections does the Applicant perform annually?___________________________

10. What type of inspection report does the Applicant use? Circle: NARRATIVE CHECKLIST VERBAL

11. What inspection standards are used? Circle: ASHI NAHI FABI GAHI CREIA OTHER____________

12. Is the Applicant affiliated with any of these professional home inspection organizations:

Circle All That Apply: ASHI NAHI FABI GAHI CREIA OTHER_______________

13. Please list the states where the Applicant performs inspection services:________________________

14. Indicate the types of inspections performed and the percentage of gross income derived from each:

    Type of Inspection Performed: % Residential home inspection less than 4 units Residential home inspection over 4 units Commercial /Industrial Insurance inspection personal lines Insurance inspection commercial lines: Other (Please explain on a separate sheet of paper) TOTAL 100%

    (Must be signed by an Owner, Partner or Senior Officer)

HI001 (8/06) Page 3 of 6

     15. Indicate the percentage of inspections performed for the following types of clients:

    Type of Client % Individual purchasers Mortgage lenders Municipalities Governmental agencies including, but not limited to HUD and FHA Other (please specify) TOTAL 100%

16. Is the Applicant a licensed real estate agent: YES/NO

     If YES:

    b. Do you inspect any homes that you have listed as a real estate agent? YES/NO

    a. Does the real estate operation carry separate professional liability coverage? YES/NO

17. Is the Applicant an exclusive home inspector for any one realtor or real estate company: YES/NO

If YES, explain:______________________________________________________________________

18. Does the Applicant currently offer estimates or do repair work on properties you have inspected? YES/NO

If Yes, please explain:_________________________________________________________________

19. Does the Applicant currently use a pre-inspection agreement when performing home inspection YES/NO

If Yes, is the agreement signed in advance by your customer? YES/NO

    (Must be signed by an Owner, Partner or Senior Officer)

    4 of 6 HI001 (8/06) Page

20. Does the Applicant offer warranties or guarantees of any type? YES/NO

If Yes, please furnish full details:_______________________________________________________________

21. Does the Applicant:

    a) Have an in-house office policy/procedures manual in place? YES/NO

    b) Use a contract for services or letter of engagement for all clients? YES/NO

    c) Require professionals to attend continuing education classes? YES/NO

    d) Use an in-house counsel, counsel on retainer and/or risk manager? YES/NO

    e) Perform audits of work performed by each professional? YES/NO

     If YES, how often? ____________________________________

22. Does the Applicant hire subcontractors? YES/NO

If YES:

    a. What percentage of gross income is performed by subcontractors:____________________________%

    b. What type of work do subcontractors perform? ___________________________________________

    c. Do you review the work performed by subcontractors? YES/NO

    d. Do you verify the qualifications of subcontractors? YES/NO

    e. Are any services performed by subcontractors outside of the U.S.A.? YES/NO

    f. Are subcontractors required to have their own E&O insurance? YES/NO

23. Has the Applicant or any other proposed insured been involved in or have knowledge

    of any disciplinary or investigative action or license revocation by any local, state or federal

    licensing board, court, regulatory authority or professional association? YES/NO

     If YES, please give full details on a separate sheet.

24. Is General Liability Insurance now in force? YES/NO

If yes, provide current company: _______________________________________

Policy Term Limit $ _______________ Deductible $ Premium $ __________________

Does the General Liability Insurance include Personal Injury coverage? YES/NO

Does the General Liability Insurance include Products/Completed Operations coverage? YES/NO

    (Must be signed by an Owner, Partner or Senior Officer)

    5 of 6 HI001 (8/06) Page

25. Has the Applicant carried Professional Liability Insurance previously under the existing name or any

    predecessor in business? YES/NO

If YES, please detail the past three years:

Insurer Limits of Liability Deductible Premium Policy Period

    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 ________________________

7. In the past 5 years, has any application for this type of insurance completed by the

    Applicant or any other predecessor in business been declined? Or has any insurance of this

    type been cancelled, non-renewed, or refused? YES/NO

If yes, please explain on a separate sheet.

26. In the past 5 years, has any CLAIM been made against the Applicant or any of their

    past or present owners, officers, partners, directors or employees either individually or

    otherwise for professional services? YES/NO

If YES, please complete the attached Claim/Incident/Circumstance Information Sheet for each claim.

27. Is the Applicant or any other person proposed for insurance aware of any incident or

    circumstance which may result in a CLAIM being made against the Applicant or any past

    or present owners, partners, officers, directors, employees or predecessors in business? YES/NO

If YES, please complete the attached Claim/Incident/Circumstance Information Sheet for each incident or

    circumstance.

28. Limit(s) of Liability requested ____________________________________________________

29. Deductible(s) requested _________________________________________________________

Signed ___ ____________________________________

    (Must be signed by Owner, Partner or a Senior Officer)

    Title _____________________________________ Date ____________________________________

    The signer of this application, authorized and acting on behalf of all Insured’s declares that all statements and information provided by the Insured’s is true, complete and accurate. It is agreed that this application is the basis of and becomes a

    part of the policy, should a policy be issued.

The signing of this application does not require the signer to purchase insurance, nor does the review of this

    application require the Insurer to issue a policy.

    (Must be signed by an Owner, Partner or Senior Officer)

    6 of 6 CLAIM/INCIDENT/CIRCUMSTANCE INFORMATION SHEET L362 (9/05) Page

This sheet is to be completed by an Applicant who has been involved in: a) any claim or suit in the past 5 years or b)

    who is aware of any incident or circumstance which may result in a claim. Please complete a separate sheet for

    each. Answer all questions fully. An Owner, Partner or Senior Officer must sign and date each sheet in addition to

    the application.

1) Is this a: CLAIM INCIDENT CIRCUMSTANCE (CIRCLE ONE)

2) Name of firm:

3) Name(s) of individual(s) of firm involved in claim/incident/circumstance:

4) Name of Claimant: 5) Date of alleged claim/incident/circumstance:

6) Date claim made (if applicable): 7) Name of Insurer (if applicable):

8) Present status of claim (if applicable): PENDING IN SUIT CLOSED (CIRCLE ONE)

9) If closed: Total indemnity paid: _________________ Total expenses paid: ___________________

10) If pending:

    Amount asked in summons: _______________________________________

    Claimant’s settlement demand: _____________________________________

    Defendant’s settlement offer: _______________________________________

    Insurer’s loss reserve: ____________________________________________

    Expenses paid to date: ____________________________________________

11) Detailed description of claim/incident/circumstance: ______________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

12) Allegations upon which the claim/incident/circumstance is based: ____________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

13) Actions taken to prevent a reoccurrence or similar claim/incident/circumstance: _________________________

___________________________________________________________________________________________

Signed: _______________________ Title: _________________________Date:___________________________

    (Must be signed by an Owner, Partner or Senior Officer)

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