BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR HOME INSPECTORS ERRORS & OMISSIONS INSURANCE.

THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE AND REPORTED IN WRITING DURING THE "POLICY PERIOD," OR ANY EXTENDED REPORTED PERIOD. THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY BE EXHAUSTED BY "DEFENSE COSTS," AND "DEFENSE COSTS" WILL BE APPLIED AGAINST YOUR DEDUCTIBLE. THE COVERAGE APPLIED FOR WITH THIS APPLICATION DIFFERS IN SOME RESPECTS FROM THAT AFFORDED UNDER OTHER POLICIES. READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING.

1. Applicant's name
2. Business name
3. Physical Address
   City  State  Zip 
4. Phone  Fax  Email 
5. Year Established



Licensed Inspectors	TREC License # or File ID #	Percent Ownership	Years licensed
		%
		%
		%
		%

6. In addition to yourself, how many employees do you have?    
7. Y   N Is applicant engaged in any other business other than Home Inspection?
   If yes, explain
8. Y   N Does the applicant currently have an Errors and Omissions insurance policy in force?
   Current Errors & Omissions limits   $ per claim, $ Aggregate $ Deductible
   Effective Date    Expiration Date    Retroactive Date   Company
9. Y   N Does the applicant currently have a General Liability insurance policy in force?
   Current General Liability limits    per occurrence, Aggregate Deductible
10. Y   N Has the applicant ever had an E & O policy declined, renewal refused, or canceled?
    If yes, explain
11. Y  N Is the applicant the exclusive inspector for any real estate agent/agency, developer and/or builder?
12. Y  N Does the applicant utilize independent contractors? (if no, please skip to 15)
13. Y  N If yes, does the application require contractors to carry their own professional liability insurance?
14. Y  N If yes, does the applicant keep Certificates of Insurance for independent contractors on file?
15. Y  N Does the applicant require a signed pre-inspection agreement for all home inspections?
16. Y  N Does the applicant always provide a written inspection report for all inspected properties?
17. Y  N Does the applicant provide referrals or recommendations for remediations or repairs needed?
18. Y  N Does the applicant provide any inspections for the following services: Wood Destroying Insects, Radon, Pools and Spas, Stucco & EIFS, Septic Systems and Water Wells, Wind Mitigation, Green Building Auditing, Infrared Thermography?
19. Y  N Does the applicant perform Mold inspections?
20. What was the approximate highest value property inspected? $
21. What was the average value of properties inspected? $
22. What was the total number of inspections performed in the last 12 months? 
23. What is the projected number of inspections to be performed in the next 12 months? 
24. What was the total gross revenue in the last 12 months from inspections? $
25. What is your projected revenue for the next 12 months from inspections? $
26. Please provide a break-down by percentage of the types of inspections you conduct (total 100%):
    Residential %        Commercial %        Other %
27. How many years do you maintain your files? 
28. Requested Errors & Omissions limits $ per claim, $ Aggregate $ Deductible
29. Requested General Liability limits $ per occurrence, $ Aggregate $ Deductible
30. Requested effective date of coverage?  
31. Y  N Has the applicant or any listed inspector been subject to disciplinary action by any State Agency?
    If yes, explain
32. Y  N Have any claims or suits been made against the applicant or any listed inspector in the last five years?
    If yes, explain
33. Y  N Is the applicant or any listed inspector aware of any issues, circumstances, errors, omissions, or offenses which may result in a claim being made against the applicant, any listed inspector, or the business?
    If yes, explain



NOTICES

The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to purchase, a policy. The Applicant will be advised if the Application for coverage is accepted. The Applicant hereby authorizes the Company to make any inquiry in connection with this Application.

Notice to Arkansas, Louisiana, Maryland, Minnesota, New Mexico and Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating . fraud against an insurer, submits an application or files a claim containing a false, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties.

Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be to reported to the Colorado Division of Insurance within the Department of Regulatory agencies.

Notice of District of Columbia, Maine, Tennessee and Virginia Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

Notice to Florida and Oklahoma Applicants: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony (in Oklahoma) or a felony of the third degree (in Florida).

Notice to Kentucky Applicants: Any person who, knowingly and with intent to defraud any insurance company or other person files application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime.

Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Notice to Oregon and Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.

Notice to Pennsylvania and New York Applicants: 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 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 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 (in New York) or criminal and civil penalties (in Pennsylvania).



ACKNOWLEDGEMENT, REPRESENTATIONS, & WARRANTIES

The applicant is authorized by and acting on behalf of all persons concerned seeking insurance, has read and understands this application and declares all statements set forth herein are true, complete, and accurate.

The applicant further declares and represents that any happening, incident, or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer and the insurer may withdraw of modify any outstanding quotations and/or authorizations to bind the insurance or the policy, if a policy is issued.

The applicant acknowledges and agrees that the submission to and the insurer’s receipt of such written report, prior to the inception of the policy applied for, is a condition precedent to coverage.

The applicant by signing this application hereby authorizes, but does not require, the underwriters and/or their representatives to contact any prior insurer and obtain any details or prior loss information or obtain any other information from any source including consumer credit information, which the underwriters deem appropriate in the underwriting of the insurance applied for by this application.

The applicant agrees that this application shall be the basis of the contract should a policy be issued and it will be attached to and become a part of the policy.

The applicant acknowledges and agrees that the affixing of the applicant’s signature to this application does not bind either the underwriter or the applicant to complete this insurance.




By placing the initials of the applicant in the box below, the applicant acknowledges acceptance of the above, and understands that the initials carry the effect of a signature.






Initials	Date	Name of applicant	Title

IBD HI (9.1.2022)