Professional Liability Application
Errors & Omissions Insurance
HOME INSPECTORS
705 West Avenue B #320 Garland, TX 75040
972 840 0832 tel   866 840 8004 tel   972 840 0189 fax
www.insurancebydesign.info
Johnny@InsuranceByDesign.info
APPLICANT ACKNOWLEDGEMENT

The undersigned understands and accepts that any policy issued will provide coverage only on a CLAIMS MADE (claim must be made during the policy period) basis and that the limit of liability to pay damage could be reduced and/or could be completely exhausted by payment of claims expense.
The undersigned accepts that a DEDUCTIBLE shall be applied against each and every claim and that failure to report a possible claim in a prompt and timely manner could cause possible claim to be denied.
The undersigned understands and accepts that if coverage is provided it is only for HOME INSPECTORS type of activities.
The undersigned agrees to read the EXCLUSIONS section of policy if issued. The undersigned understands and accepts that misrepresentation, misleading answers, incomplete answers, omissions, or FAILURE to DISCLOSE any PRE-EXISTING SITUATION or CONDITION or INCIDENT which could lead to the presentation of a claim will RELEASE the insurer from any claim payment or defense expense.
BY MY SIGNING I HAVE ACKNOWLEDGED MY READING, MY UNDERSTANDING, AND MY ACCEPTANCE OF THE ABOVE STATEMENTS.


X______________________________   
Signature                                                        Date                Printed Name                                           Title



  1. Applicant's name as appears on license  
  2. Business name (Name as you want it to appear on the policy)

  3. Street Address
    City  State  Zip 
  4. Any branch offices?  Y N If yes attach a complete listing.
  5. Phone  Fax  Email 
  6. Applicant is    Individual  Partnership  Corporation  Other
  7. Owner's Listing (Name)                                                 % of ownership    years experience     years licensed
    %
    %
    %
  8. Is applicant engaged in any other business than Home Inspection? Y N
    If yes explain  
  9. Is applicant controlled, owned, affiliated or associated with any other firm? Y N
    If yes explain  
  10. During the past 3 years has the name of the business been changed or has any other business been acquired, merged into or consolidated with the applicant? Y N
    If yes explain  
  11. E&O policy in force?  Y N Expiration date  Retro date
  12. Has the applicant ever had an E & O policy declined, renewal refused, or canceled? Y N
    If yes explain  
  13. What was total gross revenue last year?   $  Projected next year?   $
  14. What was total number of inspections?   Personal %  Commercial %  
  15. Of that total number of inspections, how many were of a value between
    $0 to $100,000              $101,000 to $150,000              $151,000 to $200,000             
    $201,000 to $250,000              $251,000 to $300,000              Over $300,000 
  16. How many years do you maintain your files? 
  17. Do you document for the file ALL business related conversations?  Y N
  18. If accepted by the insurer what is the requested effective date? 
  19. Requested limit $/$ Requested deductible $
  20. Has the applicant or any employee of the applicant ever been subject to disciplinary action by any State Agency? Y N
  21. Have any claims or suits been made against applicant or any staff member? YN
  22. After inquiry of EACH person proposed for insurance, is the applicant AWARE of any CIRCUMSTANCE, OMISSION, ERROR or OFFENSE which may result in a claim being made against the applicant or any of applicant's employees? Y N

    23. BY MY SIGNING, I AM STATING ALL ANSWERS ARE TRUE AND COMPLETE.

    X____________________________   
    Signature                                                    Date                Printed Name                                           Title




    RETURN TO

    705 West Avenue B #320 Garland, TX 75040
    972 840 0832 tel   866 840 8004 tel   972 840 0189 fax
    www.insurancebydesign.info
    Johnny@InsuranceByDesign.info