41 West Street5th Floor, Boston MA, 02111  
P-617-695-4500  F-617-426-6642
444 East 82nd Street, Suite 22B, NY NY 10028
P-202-465-4306  F-202-478-0856
www.homeinspectorliability.com
1. Requested Effective Date:
2. Name of Present Carrier:
3. Applicant Information:
Company Name:
Contact Name
Street Address
State:
City:
Zip Code:
4. Years in Business
5. Federal Employer ID Number:
6. Named Insured is:
Other explaination
7. Interest of the Insured:
8. Describe any losses in the last three years at each location.  Include date, type of
loss & amount paid: (This is for either Workers Comp and the Business Owners Policy
9. Business Liability Limits of Insurance
10. Limit of current Insurance:
11. Building Value: Not applicable if tenant$
12. Business Personal Property (Non Computer)
13. Business Personal Property (Computer)
14. Describe You Business
15. Construction
16. Code
17. Protection Class
18. Locations:
Location 1
Street Address
State:
City:
Zip Code:
Categories, Duties, Classifications:
No. of Employees:
Estimated Annual Remuneration:
Location 2 (If necessary)
Street Address
City:
State:
Zip Code:
Categories, Duties, Classifications:
No. of Employees:
Estimated Annual Remuneration:
Location 3 (If necessary)
Street Address
City:
State:
Zip Code:
Categories, Duties, Classifications:
No. of Employees:
Estimated Annual Remuneration:
The signer of this application, authorized and acting on behalf
of all Insureds declares that all statements and information
provided by the Insureds 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.
Signed
Title
Date

NACHI - The National Association of Certified Home Inspectors - The World's Elite Inspectors

First Indemnity is an
affiliate member of ASHI