APPLICATION INSURANCE THE COVERAGE AFFORDED BY A POLICY, IF ISSUED,
WILL BE ON A “CLAIMS MADE” BASIS.

PLEASE FULLY COMPLETE EACH QUESTION, INDICATE THE CORRECT
RESPONSE WHEN A QUESTION ASKS “YES” OR “NO” AND SUBMIT ADDITIONAL
INFORMATION IF REQUIRED.
Thank you for applying with First Indemnity. We are looking forward to assisting
you with your insurance needs.

This application should take about 15-20 minutes.
Application for MOLD Inspection Insurance
Company Name
If you are a Sole Proprietorship/ Individual  (Not an Inc, Partner, LLC...)  
with a DBA, please use this format: "Your Name" DBA "Your DBA Name"
First Name
Last Name
Street Address
State
 Zip
City
Telephone
Fax
Web Address
E-mail
How many Inspectors are to be
covered by this policy?               
(do not count support staff)
Year Established
New Business
Renewal
1) Coverage requested
2) Proposed Effective Date (MM/DD/YYYY)
Deductible
3) Limits of Liability/Deductible Desired
 Liability Limits
4a) List of Inspectors. Please fill out information for each inspector being covered
Fax Copies of your completed certification to 202-478-0856
Date of Mold Certification
MM/DD/YYYY
First Name
Where Trained
Last Name
4b)Does the Individual have (Select any/All that apply)
if Yes Explain
5a) Prior General Liability Carrier (fill in each category)
Carrier
 Limits
 Deductible
 Expiration
5b) Any Policy or coverage declined, Cancelled, or Non-renewed during the prior 3 years
6a) Prior Mold Inspector Errors and Omissions Liability Carrier Information (Fill in each category)
Carrier
 Limits
 Deductible
Expiration
 Retro-active date
6b) Any Policy coverage declined, Cancelled, or non-renewed during prior 3 years?
(Please fax a copy of your current declarations page to 202-478-0856)
7) All Applicants must submit the following information:

7a) Qualifications including resumes and brochures
7b) Number of estimated annual inspections to be made (choose a category)
8) Have you ever been subject to disciplinary action by authorities as a result of any
professional or contracting activities?  If yes, explain.
9) has any claim, suit or notice of incident been made against you, the firm, or any
staff member?  If yes, please fill out this claims circumstances form for each
incident and fax to 202-478-0856
10) Is the applicant aware of any circumstances which may result in any claim, suit of
notice of incident against him, the firm, his predecessors in business, any of the
present or past partners or officers, or any staff member?

If yes, please provide full details on each incident on this claims circumstances form
:
Read Carefully!

11. Agreement: The coverage which applies to individuals is provided by a “claims-made” policy.
This policy only covers those inspectors listed in the application. Coverage will apply only when:

1. You are engaged in professional mold inspection services. There is no coverage for any
other activity which includes other Home Inspection procedures.

2. You are in strict compliance with the standards promulgated by an insured’s governing State
Agency or Federal standards. You are also in strict compliance with the policy’s Appendix “A”
five inspection protocols
FRAUD WARNING: APPLICABLE TO ALL STATES
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
actual value of the claim for each such violation

WARRANTY STATEMENT
The undersigned individual applicant declares that the statements set forth herein are true. The undersigned
individual applicant agrees that if the information supplied on the application changes between the date of
the application and the effective date of the insurance, he/she (undersigned) will immediately notify the
insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or
authorization or agreement to bind the insurance. Signing of this application does not bind the applicant or
the insurer to complete the insurance.

Notice to applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any false information, or conceals for the purpose of
misleading, information concerning fact material thereto, commits a fraudulent insurance act, which is a crime.
Name
Title
Date
There are also additional Coverages available-If you are looking for Radon, Lead Paint
or Indoor air quality, please fill out the specific application for that additional
coverage and hit submit. Please fill out all sections BEFORE you hit submit
Before submitting, please print this document for your records.
OPTIONAL COVERAGES
The following optional coverages are available by endorsement. These optional coverages are subject to
additional premiums and have specific sub-limits of liability. Please check which coverages are desired.
RADON INSPECTIONS
1. Please describe the type of radon testing equipment used:
2. Describe any consulting services performed:
3. Please list all Applicants/Insureds who are licensed/certified to perform Radon Inspections:
Fax all  copy of licenses to 202-478-0856
(Please note that Applicants/Insureds not licensed/certified to perform Radon Inspections
under the laws of ALL states in which the Applicant/Insured practices will not be eligible for
Radon Inspection coverage.):
Date of Radon Certification
MM/DD/YYYY
First Name
 Where Trained
Last Name
4. Do you perform remediation?
5. Is the laboratory used EPA-listed?
6a) Number of Radon Tests in the last 12 months

6b) Number of Radon Tests in the next 12 months
There are also additional Coverages available-If you are looking for Radon, Lead Paint
or Indoor air quality, please fill out the specific application for that additional
coverage and hit submit. Please fill out all sections BEFORE you hit submit
Before submitting, please print this document for your records.
FRAUD WARNING: APPLICABLE TO ALL STATES
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 actual value of
the claim for each such violation

WARRANTY STATEMENT
The undersigned individual applicant declares that the statements set forth herein are true. The undersigned
individual applicant agrees that if the information supplied on the application changes between the date of the
application and the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of
such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorization or
agreement to bind the insurance. Signing of this application does not bind the applicant or the insurer to
complete the insurance.

Notice to applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any false information, or conceals for the purpose of
misleading, information concerning fact material thereto, commits a fraudulent insurance act, which is a crime
LEAD PAINT INSPECTIONS
1. Please describe any consulting services performed:
2. Please list all Applicants/Insureds who are licensed/certified to perform Lead Paint Inspections:
(Please note that Applicants/Insureds not licensed/certified to perform Lead Paint
Inspections under the laws of ALL states in which the Applicant/Insured practices will not
be eligible for Lead Paint Inspection coverage.):
Date of Lead Paint Certification
MM/DD/YYYY
First Name
 Where Trained
Last Name
3a. Number of Lead Paint Inspections to be performed in the Last 12 months:

3b. Number of Lead Paint Inspections to be performed in the next 12 months:
There are also additional Coverages available-If you are looking for Radon, Lead Paint
or Indoor air quality, please fill out the specific application for that additional
coverage and hit submit. Please fill out all sections BEFORE you hit submit
Before submitting, please print this document for your records.
FRAUD WARNING: APPLICABLE TO ALL STATES
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 actual value of
the claim for each such violation

WARRANTY STATEMENT
The undersigned individual applicant declares that the statements set forth herein are true. The undersigned
individual applicant agrees that if the information supplied on the application changes between the date of the
application and the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of
such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorization or
agreement to bind the insurance. Signing of this application does not bind the applicant or the insurer to complete
the insurance.

Notice to applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any false information, or conceals for the purpose of
misleading, information concerning fact material thereto, commits a fraudulent insurance act, which is a crime
Indoor Air Quality INSPECTIONS
1. Please describe any consulting services performed:
2. Please list all Applicants/Insureds who are licensed/certified to perform Lead Paint Inspections:
(Please note that Applicants/Insureds not licensed/certified to perform Lead Paint
Inspections under the laws of ALL states in which the Applicant/Insured practices will not
be eligible for Lead Paint Inspection coverage.):
Date of Lead Paint Certification
MM/DD/YYYY
First Name
 Where Trained
Last Name
3a. Number of Lead Paint Inspections to be performed in the Last 12 months:

3b. Number of Lead Paint Inspections to be performed in the next 12 months:
There are also additional Coverages available-If you are looking for Radon, Lead Paint
or Indoor air quality, please fill out the specific application for that additional
coverage and hit submit. Please fill out all sections BEFORE you hit submit
Before submitting, please print this document for your records.
FRAUD WARNING: APPLICABLE TO ALL STATES
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 actual value of the claim for each such
violation

WARRANTY STATEMENT
The undersigned individual applicant declares that the statements set forth herein are true. The undersigned individual
applicant agrees that if the information supplied on the application changes between the date of the application and the
effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such changes, and the insurer
may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. Signing of
this application does not bind the applicant or the insurer to complete the insurance.

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