1.
 
 
 
 
 
 
 
2.
 
3. Is the Applicant or any other proposed insured
  (a)
  (b)
 
4.
5. Please detail the number of partners and staff
  (a) Principals/Partners/Inspectors (owners)
   
  (b) Professional Staff /Inspectors (non-owners)
   
  (c) Other Employees (helper/apprentices)
   
6. Please detail the following for all owners, officers, directors, partners and inspectors: Owner, Employee and Independent Contractor
 

 
Name Designation
  # {{$index + 1}}
7. Inspections by year
 
  Gross Revenue # of Inspectors Total Inspections
Next 12 Months
$
Last 12 Months
$
12 to 24 Months ago
$
8.
$
 
 
$
9.
 
10.
 
 
 
11.
12.
 
13.
14. Indicate the types of inspections performed and the percentage of gross income derived from each
 
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
{{TypesofInspections.Total | currency:"":2}} %
15. Indicate the percentage of inspections performed for the following types of clients
 
%
%
%
%
%
{{Application.TotalInspectionPerformed | currency:"":2}} %
16.
 
17.
 
18.
 
19.
 
20.
 
21. Does the Applicant:
  (a)
  (b)
  (c)
  (d)
  (e)
 
22.

If YES:

  (a)
%
  (b)
  (c)
  (d)
  (e)
  (f)
23.
 
24.
 

 
Insurer Limits Deductible Premium Period
  # {{$index + 1}}
$
 
 
25. (a)
  (b)
  (c)
26. Limit Options: Professional Liability (Errors & Omissions) Coverage:
 
27. Deductible
 
28. Please select any additional coverages that you might want
 
   

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