Applicant Information - Proposed Insured

Contact Name:*			Company Name:*
DBA:			Street Address:*
City:*			State: *	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:*			Business Phone: (xxx) xxx-xxxx*
Email Address:*

Background Questions

1. How many consecutive years of inspection experience do you have?	Select an Option   <3 3-5 5-10 10+
What additional training, certification and experience have you pursued for your property inspection business?
2. Do you manage other inspectors in your company that you would want this policy to cover?	yes no
Enter Number of other inspectors in your company that you manage?
3. Of which of the following professional association or groups are you currently a member?	ASHI NAHI NACHI Other
What other professional association or groups are you currently a member?
4. Please describe any certification you currently hold:
5. Estimated annual revenue from inspections? (Numbers Only)
6. Do you comply with all of the regulations regarding inspections, for the states in which you work?	yes no
7. Have any claims or suits been made against you pertaining to your inspection work in the past 5 years, or do you know of any circumstance that may lead to a claim?	yes no
First Claim
Claim date:
Claim amount:
Description of claim:
Second Claim
Claim date:
Claim amount:
Description of claim:
Third Claim
Claim date:
Claim amount:
Description of claim:
8. Do you currently carry professional (E&O) or general liability insurance?	yes no
When did you start your current coverage?	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10111213141516171819202122232425262728293031 Year 201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953
9. What is your desired date for our insurance to become effective for you? (ie: mm/dd/yyyy)
10. Would you like to select coverage for mold, Radon, and wood-destroying (termite) inspections?	yes no
11. Are you required to carry a Crime/Fidelity bond in the state(s) in which you work?	yes no
What amount of Crime/Fidelity bond are you required to carry?	$ 5,000 amount for a fee of $42.50/year $10,000 amount for a fee of $85.00/year $15,000 amount for a fee of $127.00/year $25,000 amount for a fee of $212.00/year
Who referred you?
12. Please select the level of desired coverage?	Select a Coverage   $1,000,000 $500,000 $300,000 $100,000

E-Signature

Please click the check box below, enter the 5 digit code, and the "Submit Application" button to process your enrollment form.

I affirm I have answered all of the questions truthfully and correctly to the best of my knowledge. I understand and agree that the insurance company will rely on my electronic signature on this application to fulfill part of the insurance process.*

* I understand that I am not obligated to enter into transactions electronically and that I have a right to conduct insurance transactions in paper format if I wish. By clicking the "Submit Application" button below, I affirmatively consent to conduct this transaction in electronic form.

5-Digit Code:*