HOME INSPECTORS
PROFESSIONAL LIABILITY INSURANCE APPLICATION
NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE DEDUCTIBLE.
A. Please
type or complete the application in ink.
B. If
additional space is needed, please use your firm’s letterhead.
1. Applicant Name:
2. Address
1:
Address
2:
City: State: Zip Code:
2. Contact Name:
Phone:
3. Type of Business:
Individual, Partnership, Corporation, Limited Liability Corporation
5. Year
Established:
6. Effective Date of Operations:
7. Description of Operation:
8. Does any member of the Applicant provide services outside the scope of Home Inspection? Yes, No
(If "yes", please provide full details)
9. To what Professional Association(s) does the Applicant belong?
10. Number
of Inspectors: #
11. Projected
Annual Revenues: $
12. Total
Revenue from Commercial Inspections: $
13. Prior
Year Total Gross Revenues: $
14. Is
a Pre-Inspection Agreement/Contract signed 100% of the time? Yes, No
15. In the past five years, has any professional liability claim or suit been made against the applicant or of its predecessor firms if any? Yes, No
(If "yes", please complete the Claim Supplement)
16. Please list the Applicants Professional Liability Insurance Coverage carried during the past year, including any periods without coverage.
Previous Year Expiring Expiring Expiring
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
17. Retroactive
Date of Current (claims made) Policy:
18. Limits Desired: Deductible
Desired:
19. Optional Coverages or Endorsements (check if coverage is desired):
Premises Liability (subject to sub-limit): $ 100,000, $ 250,000, $ 300,000
Wood Destroying
Organisms/Termite Inspection (subject to sub-limit)
Radon Inspections/Sample
Collections (subject to sub-limit)
Prior Acts Coverage (available
for Occurrence form only)
Franchisor Additional Insured
Endorsement - Name and complete address of franchisor to be added:
ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURANCE COMPANY WHICH THIS APPLICATION IS SUBMITTED (HEREIN CALLED THE COMPANY) IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE PART HEREOF. THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY, OR THE COMPANY TO ISSUE THE INSURANCE, BUT IT AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND MADE PART OF THE POLICY. THE UNDERSIGNED APPLICANT DECLARES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY IS ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.
Signature of Owner, Partner or
Principal
Title Date
IF A POLICY IS ISSUED THE APPLICATION
IS ATTACHED TO AND MADE PART OF THE POLICY SO IT IS NECESSARY THAT ALL
QUESTIONS BE ANSWERED IN DETAIL.
PLEASE READ THE FOLLOWING CAREFULLY
AND SIGN BELOW WHERE INDICATED. IF A POLICY IS ISSUED, THIS SIGNED STATEMENT
WILL BE ATTACHED TO THE POLICY.
The Applicant hereby acknowledges
that he or she or it is aware that the limit of liability contained in this
policy shall be reduced, and may be completely exhausted, by the costs of legal
defense and, in such event, the Company shall not be liable for the costs of legal
defense or for the amount of any judgement or settlement to the extent that
such exceeds the limit of liability of this policy.
The Applicant hereby further
acknowledges that he or she or it is aware that legal defense costs or defense
expenses that are incurred shall be applied to the deductible amount.
Signature of Owner, Partner or
Principal
Title Date
Signature of Witness/Broker
Signed
At Date