CHI Home Inspector Insurance > Errors & Omissions Application

Errors & Omissions Online Application
 
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* If you would like to receive a pdf copy of this application to print and fill out by hand, just submit your contact information here
Name: * Phone: * Email:
1. Contact Information
Name of Applicant (Full Business Name):
Street Address:
Mailing Address:
City: State: Zip:
Phone: Fax:
Cell: Email:
Website Address:
2. Provide the Address(es) of all Branch Office(s) and/or subsidiaries. Describe their operations and indicate if coverage is
    desired. For multiple branches and/or subsidiaries, please attach additional sheets.
Branch Office / Subsidiary:
Description of Operations:
Street Address:
Mailing Address:
City: State: Zip:
Phone: Fax:
3. Date Established:
4. The Applicant is:
5. Is your business a Franchise?
If "Yes", provide full details below.
6. Applicant owned by, controlled by or affiliated with another entity or does the applicant own or control
    any other firm?
  
If "Yes", provide full details below.
7. During the past 5 years, has the name or ownership or the applicant changed or has there been an
    acquisition, merger, consolidation or other changes?
  
If "Yes", provide full details below.
8. Provide the number of the Applicant's Staff broken down into the following categories.
    Full Time Part Time
a. Inspectors/ Principals/Partners/Officers/Directors a.
b. Other Employees (secretaries, clerks, bookkeepers, etc.) b.
9. What is the annual employee payroll (excluding principal compensation) $
10. Does the Applicant use Subcontractors to perform professional services?   
11. Provide the following information on all principals, key employees, and subcontractors:
Full Name No. Years Experience Professional Qualifications Time With Applicant
12. (a) Are all home inspectors licensed?   
(b) If "No", are individual inspectors required to be licensed in the state(s) in which inspections
     are performed?
    
(c) Please list all states in which the applicant does business:
(d) Have you, your company, or staff ever had your license revoked, suspended, been formerly
     reprimanded, or been the subject of a disciplinary inquiry or action?
  
If "Yes", provide full details below.
13. Does the applicant or any inspector hold other professional licenses, is engaged in any other business
      or is employed by any other business or company?
  
If "Yes", provide full details below.
14. a. Proved Estimated gross receipts for the NEXT fiscal year:
Gross Receipts $
b. Provide the gross receipts for the current year and the past TWO years.
20 $
20 $
20 $
15. Indicate type of properties the applicant inspects. If this is a new venture provide estimates.
Inspection Type Percentage of Revenue   Number of Inspections Annually Average Inspection Fee
Existing Residential 1 to 4 units %
Exisiting Residential Over 4 Units %
Condominiums / Town Homes / Duplexes %
Modular Homes %
Mobile Homes %
Log Homes %
Farms / Ranches %
Existing Commercial %
Existing Industrial %
New Construction - Residential %
New Construction - Commercial %
New Construction - Industrial %
Other:
%
100% Total
16. Indicate type of inspections. Check all boxes that apply.
Note that checking off the type of inspections does not consitute coverage for those service. Coverage terms offered are subject to
determination by the Insurance Company or its authorized representative. If there are any questions, please consult with your agent,
broker or attorney.
17. Will an inspector perform more than two inspection per day?   
If "Yes", provide full details below:
18. Will you partner up with another individual or company to perform home inspections?
If "Yes", provide full details below:
19. Provide percentage of your annual income from the following sources (must equal 100%):
Individual Seller / Individual Buyer / Real Estate Agency %
Lender / Mortgage Company / Mortgage Broker %
Developer / Investor / Syndicator / Relocation Company %
Insurance Company %
Other (explain):
%
20. Does any single client represent more than 15% of the Applicant's annual revenue?
If "Yes", provide full details below:
21.Are inspection services performed on properties in which the applicant, any business partner, officer, director, franchise company or employee have direct or indirect interest, or operate as a builder, contractor, repair company, sell materials or furnish any type of product or service?
  
If "Yes", provide full details below:
22. Is a Pre-inspection agreement signed, by the customer, in advance of each inspection?   
23. Do you offer any express, verbal, or written warranty?   
If "Yes", provide full details below:
24. Indicate type of inspection report used:
(a) What type of computer software do you use to generate inspection reports?
(b) Does the software provide automatic updates?   
(c) Are digital photos of the inspected property included?   
25. (a) What Professional Associations are you a member of? (check all that apply)
(b) If none, do you participate in a formal risk management program?
Provide Program Information:
26. What SOP's and code of ethics are used?
27. Provide applicable training and education:
(a) Have all inspectors taken and passed a NACHI, ASHI, CREI or other National or State, course exam?   
(b) How many hours of continuing education do inspectors complete annually?
(c) Have all inspectors completed a minimum or 80 hours of classroom work?   
If "No", provide full details below:
Provide any additional information on education or training:
28.Has any application for this type of insurance made by the Applicant or its predecessors in business ever been declined, or has any similar insurance ever been cancelled, non-renewed, refused, or had special terms imposed?   
If "Yes", provide full details below:
29.Has any Claim been made during the last FIVE years against the Applicant, any of its past or present owners, officers, partners, directors, or employees, either individual or otherwise on account of errors or omissions?   
If "Yes", provide full details below:
30.Has the Applicant ever paid an uninsured loss out of its own funds?   
If "Yes", provide full details below:
31.Is the Applicant aware of any circumstances, or any allegations or contentions, as to any incident which may result in a Claim being mage against the Applicant or any past or present owners, partners, officers, employees, or predecessors in business?   
If "Yes", provide full details below:
32. (a) Does the applicant have an in force General Liability insurance policy?   
Provide the following information about your General Liability policy:
Insurance Co. Policy Limit Effective Date Expiration Date
(b) If not, do you desire an optional quotation for General Liability coverage?   
33.(a) Has the named Applicant had errors and omissions insurance previously; either under their existing name, or that of any predecessor in business?   
If "Yes", provide full details of errors and omissions coverage for the last THREE years.
Insurance Company Policy Limit Deductible Premium Eff. Date Exp Date
$ $
$ $
$ $
(b) Is the Applicant's expiring policy a CLAIMS MADE policy?
If "Yes", provide the retroactive date and attach a copy of the expiring policy:
34. Errors and Omissions Liability Limits Desired:
35. Provide the following with your application:
      (Not required for quote purposes, contact Dave Wicker with any questions at 315-552-5334)
  • If in business less than 3 years, resumes of key personnel providing services
  • Five years of currently valued loss runs. If insured for less than 5 years, provide maximum available
  • Specimen Pre-inspection Agreement
  • Specimen Inspection Report
  • Copies of all licenses
  • Copies of Membership Certificates
  • Marketing Materials
  • Copies of any warranties or Hold harmless agreements
  • Copy of expiring Professional Liability policy
Home Inspector Experience Resume
Company Name: Date:
Inspector(s) Name:(s)
Estimate how many fully paid inspections to date:
# of Mentored or free Inspections performed:
Did you have a mentor to teach you how to do home inspections?
Name:
How many estimate hours completed through attending classes:
Do you belong to any Home Inspection Association?
Did you attend a home inspections school? Please list:
Education Explain and Years
Construction Experience and construction trade experience Explain and Years
Did you pass the home inspection national exam or any other home inspection exam?
Have you managed any property or built you own home?
Employment experience if any in the last 10 to 15 years, forward professional resume if able:
Do you have any code certifications in any area and do you have any other certifications or training. Do you have any Professional Licenses? Please List:
Read Terms and Fraud Warnings

 
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