POLARIS - Home Inspectors Professional Indication Form

• Effective date:		• Year Established:
• Projected Annual Revenue:		• Number of Inspectors:
• Revenue from Commercial Inspections:		Current Expiration Date:

• Is a Pre-Inspection Agreement Signed 100% of the time?		Yes No

• In the past five years has any professional liability claim or suit been made against the applicant or predecessor firms?		Yes No
If yes, have any been more than $5,000?		Yes No
If more than $5,000, please list the amount:
Select the Combined Limit Requested:
• (Each occurrence/Aggregate):		Deductible:
Select the Optional Endorsements Requested: (Premises Liability is strongly recommended)
Premises Liability Endorsement¹		Sub-Limit:²
Wood Destroying Organisms/Termite Inspection Radon Inspections/Sample Collections
¹ The Premises Liability Endorsement modifies the policy to cover General Liability exposures resulting in 3rd party bodily injury or property damage during theperformance of a home inspection. ² Sub-Limit cannot be greater than aggregate.
This is an application for an indication only. To receive a bindable quote a full application must be submitted along witha copy of your standard inspection agreement, 3 years' recently valued loss runs, and resumes of all inspectors with lessthan 3 years' experience. Coverage may not be available in all states. Coverage may be placed with a non-admittedcarrier subject to surplus lines taxes and fees. Actual policy will determine coverage.


	Copyright 2006 Polaris Risk Management & Insurance Services. All rights reserved.