SPMGA Southern Preferred MGA, Inc.
13465 Midway Road, Suite 202
Dallas, TX 75244
214-703-9900 - Fax 214-703-9624
HOME INSPECTOR 2022 ERRORS & OMISSIONS RENEWAL APPLICATION
  1. Applicant's name
  2. Business name
  3. Physical Address
    City  State  Zip 
  4. Phone  Fax  Email 

  5. Licensed Inspectors TREC License # or File ID # % of ownership years licensed
    %
    %
    %
    %
    %
  6. What was the total gross revenue in the last 12 months from inspections?   $
  7. What was the total number of inspections performed in the last 12 months? 
  8. Y  N Has the applicant or any listed inspector been subject to disciplinary action by any State Agency?
  9. Y  N Have any claims or suits been made against the applicant or any listed inspector in the last five years?
  10. 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?
  11. Please describe any recent claims or issues which might result in a claim

    APPLICANT CERTIFICATION

    I certify that I have read the questions above, and have answered each truthfully and completely to the best of my knowledge

    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





POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM
INSURANCE COVERAGE

You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act, as amended: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security and the Attorney General of the United States, to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Any coverage you purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2027, the date on which the TRIA Program is scheduled to terminate, or the expiry date of the policy whichever occurs first, and shall not cover any losses or events which arise after the earlier of these dates.

YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS 80% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A USD100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS USD100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED USD100 BILLION, YOUR COVERAGE MAY BE REDUCED.

THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.

 

 

 

I hereby elect to purchase coverage for acts of terrorism for a prospective premium of USD100

X

I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand that I will have no coverage for losses arising from acts of terrorism.

 

 

Policyholder/Applicant's Signature

Dale Syndicate on behalf of certain underwriters at Lloyd's

 

TBD

Print Name

Policy Number

 

Date