Application for Property Inspection Professional Liability

Application for Property Inspection Professional Liability
Please answer all questions and request for supporting documentation. If there is insufficient space to complete an answer, please provide the complete answer on attached documents. This form must be completed signed and dated by a principal, partner, or officer of the firm.

Note: The insurance for which you are applying is written on a claims made and reported basis. The policy requires that a claim be first made against you during the policy period and reported to the Insurer, in writing, during the policy period or automatic extended reporting period. The policy applied for contains provisions which limit the amount of claim expenses the Insurer is responsible to pay in connection with claims. Claim expenses shall be subject to any deductible amount and the payment of claim expenses will reduce the limits of liability. If you have any questions about coverage, please discuss them with your licensed insurance representative.
Applicant’s official business name: (to be used as named insured)*
Street Address (official)*
City*
State*
Zip Code*
Street Address (mailing)
City
State
Zip Code
Telephone*
I give RealCare permission to text me if they are not successful reaching me by phone.
Website
Contact Name*
Email*
example@example.com
1. Date firm was established*

MonthDayYear
Date
Entity Type*
(Sole proprietor, corporation, etc.)
Is the applicant a C.A.R. certified home inspector?*

YesNo

2. Has the applicant ever conducted business under a different name or entity?*

Yes (upload details on next page)No

If Yes to #2, provide details on a separate sheet and UPLOAD HERE:

If the applicant has ever conducted business under a different name or entity, upload details here.
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3. Do any other entities, or individuals not employed by your firm, have any ownership interest in the firm?*

Yes (upload details on next page)No

If Yes to #3, provide a list of all owners indicating their percentage of interest and UPLOAD HERE:

If any other entities or individuals have ownership interest in the firm, upload a list of all owners here.
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4. Is your firm a franchisee?*

Yes (provide the name of the franchisor next page)No

If Yes to #4, please provide the name of the franchisor:
If your firm is a franchisee, provide name of the franchisor here.

5. Does your firm or any KEY PERSONNEL own any interest in any other entity?*

Yes (upload details on next page)No

If Yes to #5, provide the name of owner, amount of ownership, name of the entity, relationship to your firm, nature of activities, and the entity's RECEIPTS during the last complete year. Provide this information on a separate sheet and UPLOAD HERE:

If the firm, or key personnel within the firm, own interest in another entity, upload details here.
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6. List the total Number of Personnel:*

	Licensed Inspectors	Non-licensed Inspectors	Independent Contractors	Admin/Other	TOTAL Personnel
Total # of Personnel (if none, enter "0")

7. Does anyone affiliated with your firm hold any other professional designations?*

Yes (provide details on next page)No

If Yes to #7, provide details on any additional professional designations such as, but not limited to, architecture, engineering, construction management, land surveying, real estate, appraisal, investment services, etc.:
If anyone in your firm has other professional designations, list them here.

8. Provide the following information for all Independent Inspectors:

	Name	Does the inspector work exclusively for your firm?	How many hours per week does the inspector work for your firm?	Does the inspector carry their own professional liability insurance equal to or greater than your limits?
1)
2)
3)

9. Does your firm have Branch Offices?*

Yes (upload details on next page)No

If Yes to #9, attach a list of any other office locations with the percentage of your firm’s GROSS FEES derived from each location for the last complete fiscal year. Provide this information on a separate sheet, and UPLOAD HERE:

If your firm has branch offices, upload details here.
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10. What percentage of services provided by your firm were outside United States during the last complete fiscal year? (Attach geographic locations of all foreign projects)*

	Percentage of Services
% in U.S.
% Foreign

11. Provide your fiscal year end dates for last two years:*

	Projected Fiscal Year	Current Fiscal Year	Last Completed Fiscal Year	Second Last Completed Fiscal Year
Fiscal Year End Dates

Provide your firm’s GROSS REVENUES attributable to this year, next year, and the past two years. (Gross revenues means the approximate dollar amount of your firm’s gross revenue, but not including interest income, rental income, or sales and service taxes.)*

	Gross Revenues Projected Fiscal Year	Gross Revenues Current Year	Gross Revenues Last Fiscal Year	Gross Revenues Second Last Fiscal Year
Residential Properties 1-4 units
Residential Properties 4+ units
Commercial Properties
*Other (provide details below)
TOTAL gross revenues

Provide your firm’s NUMBER OF INSPECTIONS attributable to this year, next year, and the past two years. *

	# of Inspections Projected Fiscal Year	# of Inspections Current Year	# of Inspections Last Fiscal Year	# of Inspections Second Last Fiscal Year
Residential Properties 1-4 units
Residential Properties 4+ units
Commercial Properties
*Other (provide details below)
TOTAL # of inspections

*Details from "Other" properties above:
If you had fees and inspections from properties categorized as "Other," provide a description and details here.
12. Percentage of Gross Fees annually derived from your firm’s largest client:*

13. Is the applicant the exclusive inspector for any real agency, developer, and/or builder?*

Yes (provide details on next page)No

If Yes to #13, provide details here:
If the applicant is the exclusive inspector for any real agency, developer, and/or builder, provide details here.

14. Provide the percentages, based on your firms GROSS FEES, attributable to the following inspection services (if none, enter "0"):*

	Percentage (%) of Gross Fees
Termite/Wood Destroying Insects
Radon
EIFS/Stucco
Septic / Water Purification
Roof
Wind Mitigation
Green Building / Auditing
Infrared Thermography
Pool & Spa
Chimney

15. For the last fiscal year, please enter the approximate percentage of your firms GROSS REVENUES attributable to the following Client Types (if none, enter "0"):*

	Percentage (%) of Gross Fees
Developers
Lender / Mortgage / Financial Institution
Individual Seller / Prospective Buyer / Real Estate Agency
Public Sector
Other *(provide details below)

For Clients categorized as "Other," provide details here:
Provide description of clients categorized as "Other"

17.

Tier 1 – Commercial Inspections included in Standard Inspections: Apartment, Office, Retail, Warehouse

Tier 2 – Other than Standard Commercial Inspections. Available with Qualifications (complete table below)
a. Does the applicant sub-contract out any part of the inspection service*

YesNo
If yes to 17a, does the sub have their own Professional Liability (E&O) and General Liability coverage?

YesNo

Tier 2 Table – Other than Standard Commercial Inspections

	# of Projects Past 3 years	Average Square Footage	Average # of Floors	Any buildings over 15 floors?	Construction Values (if known)
Mixed Use Buildings
Residential Balcony Inspections
Banks/Financial Institutions
Warehouse Facilities with Special Purpose*
Industrial Buildings
Hotels/Motels/Resorts
Restaurants/Cafes
Entertainment Venues (for example: Theaters)
Arts/Galleries/Studios
Arenas/Stadiums/Sports Complexes*
Educational Facilities
Hospitals/Healthcare Centers (outpatients facilities)
Spas/Fitness Centers/Gyms
Water/Wastewater Treatment Facilities
Bulkhead, Seawall or Dock Inspection (commercial)*
Automotive Repair Shops*
Gas Stations (with or without convenience store)*
Other (please define)

18. Provide the following about your firm’s Professional Liability insurance program:*

	Insurance Company	Policy Period	Limits (per claim/aggregate)	Deductible & Deductible Type	Premium	Privacy & Net (yes/no)
Current Policy
Previous Year
Previous Year
Previous Year
Previous Year

a. Retroactive date on current policy:*
If you have Full Prior Acts enter “Full." If you are currently uninsured, enter "None."
b. Does your current policy have Specific Additional Limit Endorsements?

Yes (upload details below)No
If Yes to 17. b., please provide details on separate sheet and UPLOAD HERE:

If your current policy has Specific Additional Limit Endorsements, upload details here.
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c. Provide the following about your firm’s current General Liability insurance program:

	Insurance Company	Policy Period	Limit	Deductible	Premium	Privacy & Net (yes/no)
Current Policy

18. Claim Awareness: Claim(s) means a demand received by the Insured for money or services and which alleges a wrongful act. Claim(s) includes but is not limited to lawsuits, petitions, arbitrations or other alternative dispute resolution requests filed against the Insured.*

	Yes	No
a. After inquiry, do any directors, officers, principals, partners, insurance managers, of the firm for which coverage is sought, have knowledge of any incident, a circumstance, an event, or unresolved fee dispute that may result in a claim? If “Yes,” attach the following details: Project Name, Claimant, Nature of Damages
b. Within the past five (5) years, have any claims been made or legal action brought against the firm, its predecessor(s), or any past or present principals, partners, insurance managers, or employees? If “Yes,” attach the following details: Project Name, Claimant, Nature of Damages (include dollar amount), Dates

If yes to 18 a, b, or c, provide the following details: project name, claimant, nature of damages (include dollar amount), dates. Provide this information on a separate sheet and UPLOAD HERE:

If yes to 18a, 18b, and/or 18c, upload details here.
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18. Quotation Options:

Indicate which options your firm wishes quoted for professional liability insurance:
Limits
Deductible
First Dollar Defense?

YesNo
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

I / We declare that if the firm or any of its members become aware of any information that would change answers furnished in the application, the firm will reveal such information in writing to the Company prior to the effective date of coverage.

On behalf of the applicant firm, I declare that this application, including attachments, supplementary pages and other exhibits attached, is complete and correct to the best of my knowledge and belief. I understand that the application shall form the basis of the contract of insurance should the Company offer coverage and should the firm accept the Company’s quotation. I also understand that completion of this application does not bind the Company or broker to provide insurance.
Signature of Principal, Partner, Officer, or Director*

Clear
Date of Application*

MonthDayYear
Date
Should be Empty: