Company Name
If you are a Sole
Contact Person
Street Address
Zip
State
City
Telephone
County
Fax
Web Address
E-mail
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Before 1990
How many Inspectors are to be
Year Established
1)
Individual
Partnership
Corporation
LLC
Other
Form Of Business
Proposed Effective Date
Application Type
Please Note-You are only considered an You are not
New
Renewal
Jan
Feb
Mar
Apr
May
June
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2011
2012
2) Is your Business a Franchise?
Yes
No
If Yes, Please list The Franchise company
Is the Applicant or any other proposed insured
3)
Yes
No
a) Owned by, controlled by or act as a Director or Officer of any other
Yes
No
b) engaged in any other business or employed by any other business or
If Yes, please explain
If YES, what percentage of inspection services are performed for such
In the past FIVE years has the name of the Applicant been changed or
4)
Yes
No
If Yes, Please explain
5) Please detail the number of partners and staff
Full Time
Part Time
Principals/Partners/Inspectors (owners)
Inspectors (non-owners)
Other Employees
6)
Please detail the following for all owners, officers, directors, partners and inspectors:
O=Owner E=Employee IC= Independent Contractor
Professional
Completed
Estimated Gross Est # of
Total Inspections/Year
7)
Please detail annual gross income
Year
New
Estimate for NEXT year 2011-12
Estimate for THIS year 2010-11
2009-10
Estimate for LAST year
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?
Yes
No
# Of Picts
9) Do you takes pictures during your inspection?--If Yes How many
NARRATIVE
CHECKLIST
VERBAL
Computer Program
What type of inspection report does the Applicant use? (Select all that apply)
10)
ASHI
NAHI
FABI
GAHI
CREIA
NACHI
Other
11)
What inspection standards are used
If Other, please list
ASHI
NAHI
FABI
GAHI
CREIA
TREC
NACHI
Other
Is the Applicant affiliated with any of these professional home inspection
12)
If Other, Please list the other organization
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
13)
Please list the states where the Applicant performs inspection services:
Indicate the types of inspections performed and the percentage of gross income derived from each- If the answer is 0% Please Leave 0% in the Answer Box
14)
Type of Inspection Performed:
Residential home inspection – less than 4 units
Residential home inspection – over 4 units
Soft Commercial (retail, business parks, office buildings)
Pest/WDO/WDI/Termite (excluded See option coverage section)
Lead (excluded See option coverage section)
Mold/Indoor Air Quality (Excluded-See additional coverage section)
Septic/Sewer
Pools/Spa's
Seller Inspections
Green Certification
Energy Audits
Water Quality Testing
HUD Inspections
Please describe the types of HUD Inspections
Total (Must equal 100%)
15)
Indicate the percentage of inspections performed for the following types of clients
Individual purchasers
Mortgage lenders
Municipalities
Governmental agencies including, but not limited to HUD and FHA
Total (Must Equal 100%)
Yes
No
16) Is the Applicant a licensed real estate agent
If Yes, Do you inspect any homes that you have listed as a real estate agent?
Yes
No
N/A
Yes
No
N/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
If Yes, please explain
18) Does the Applicant currently offer estimates or do repair work on properties
Yes
No
If Yes, please explain
19) Does the Applicant currently use a pre-inspection agreement when performing
Yes
No
If Yes, is the agreement signed in advance by your customer? Also, please fax a copy of the pre-inspection agreement to:
Yes
No
20)
Does the Applicant offer warranties or guarantees of any type?
Yes
No
If Yes, Please furnish details.
Does the Applicant:
21)
Yes
No
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?
If YES, how often?
No
Yes
22)
Does the Applicant hire subcontractors?
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?
Not App
Yes
No
d. Do you verify the qualifications of subcontractors?
Not App
Yes
No
e. Are any services performed by subcontractors outside of the U.S.A.?
Not App
Yes
No
f. Are subcontractors required to have their own E&O insurance?
Not App
Yes
No
Yes
No
Has the Applicant or any other proposed insured been involved in or have
23)
If YES, please give full details
Yes
No
Has the Applicant carried Professional Liability Insurance previously under the
24)
Yes
No
Is the Applicant’s expiring policy issued on a CLAIMS MADE basis?
If YES, please provide the Retroactive Date of the expiring policy. Not the current years start date , Retro-active date is the start date that you started continuous and
MM/DD/YYYY
25a) In the past 5 years, has any application for this type of insurance completed
Yes
No
If yes, please explain below
25b)
Yes
No
In the past 5 years, has any CLAIM been made against the Applicant or any of
If YES, please complete the attached Claim/Incident/Circumstance Information Sheet for each claim
Yes
No
Is the Applicant or any other person proposed for insurance aware of any
26)
If YES, please complete the attached Claim/Incident/Circumstance Information Sheet for each incident or circumstance
Optional Coverages
Termite Coverage
Yes
No
Estimated Revenue for the next 12 months
Yes
No
N/A
Do You Provide treatment? If yes Explain
Lead Inspection Coverage
Yes
No
Estimated Revenue for the next 12 months
Yes
No
N/A
Do You Provide treatment? If yes Explain
Mold Inspection Coverage
Yes
No
Estimated Revenue for the next 12 months
Yes
No
N/A
Do You Provide treatment? If yes Explain
30) Limit(s) of Liability requested Deductible(s) requested
31)
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$300,000/$600,000
$500,000/$500,000
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,0000
$2,000,0000/$2,000,0000
$1,000
$2,500
$5,000
$10,000
$20,000
Quote 1
$1,000
$2,500
$5,000
$10,000
$20,000
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$300,000/$600,000
$500,000/$500,000
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,0000
$2,000,0000/$2,000,0000
Quote 2
Quote 3
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$300,000/$600,000
$500,000/$500,000
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,0000
$2,000,0000/$2,000,0000
$1,000
$2,500
$5,000
$10,000
$20,000
32)
What coverages are you looking for?
Pest Sub-Limit Desired-
General Liability
General E and O
Radon
Referral
Lead
Pool and Spa
Mold If Desired- Mold application
Washington State
Code
Additional Insured for Franchises
Energy Audits
Detection of Water and Moisture
Other
Comments
The signer of this application, authorized and acting on behalf of all Insureds .
Signed
Title
Date
Before submitting, please print this document for your records.
Thank you for the chance to earn your business. If you have any questions, please call John Also, please do not forget to Fax/E-mail a copy of your pre-inspection agreement and . The Fax number is 202-478-0856
Broker Information
Company Phone
Name
Fax
E-mail
Internal Tracking (if necessary)
Date quote needed by
