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Organization of Real Estate Professionals (OREP)

6760 University Ave, Suite #250, San Diego, CA 92115

Phone: (888) 347-5273 * Fax: (619) 704-0567 or (619) 269-3884

email: inspectors@orep.org * www.orep.org

David Brauner Insurance Services Calif. Lic. #0C89873

OREP-Organization of Real Estate Professionals Insurance Services, LLC

Calif. Lic. 0K99465

OREP Home Inspector Professional Liability (E&O)

Insurance Application

Page 1

CLAIMS-MADE WARNING FOR APPLICATION

THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THIS POLICY WILL APPLY ONLY TO CLAIMS FIRST MADE AGAINST THE INSUREDS AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD THAT MAY APPLY. PLEASE READ THE POLICY CAREFULLY TO DETERMINE RIGHTS, DUTIES, COVERAGE AND COVERAGE RESTRICTIONS.

APPLICATION INSTRUCTIONS

ATTENTION:Please use this Application if you live in NY or HI.

Whenever used in this Application, the term the Applicant shall mean the Named Insured and all subsidiaries, unless otherwise stated.

GENERAL INFORMATION


Yes No

0-3 Years 4-6 Years 7 or more

0-3 Years 4-6 Years 7 or more


Yes No

Yes No
Name of Subsidiary % Owned Year Started Description of Operations Entity Type*
*Entity Types : FP=For-Profit (other than Partnership) NP=Non-Profit GP=General Partnership LP=Limited Partnership LLC= Limited Liability Company SP=Sole Proprietorship. To enter more information, please attach a separate page to the application.
IMPORTANT : It is understood and agreed that coverage is not provided for additional companies/subsidiaries in Question 6. unless the information requested above is provided.
Staff

(Including yourself)

# Full Time # Part Time
Home Inspectors
Non-professionals

Yes No
Name

(Please include additional names on a separate sheet)

Does inspector work exclusively for the applicant firm? How many hours per week does the inspector work for the applicant firm? Does inspector have professional liability insurance coverage with limits the same as or higher than applicant carries?
Yes No Yes No
Yes No Yes No
Yes No Yes No

Yes No

Yes No

(Note: coverage is for inspection services only.)


Yes No

Pest, Termite, Radon or Mold License

Yes No

Note: coverage is for inspection services only.


Other: Please List

Yes No

Note: coverage is for inspection services only.

(By submitting this application, applicant agrees that coverage does not apply to professional services other than those that are home inspection related. Please contact OREP with any questions. )

Current Year Most Recently Completed Fiscal Year

If you are a new inspector, please include a reasonable projection of revenue under current year.

Income Number of Inspections Income Number of Inspections
Residential 1-4 units $ $
Residential over 4 units $ $
Commercial $ $
Other (please explain) $ $
Total $ $
Individual Seller / Prospective Buyer / Real Estate Agency: %
Lender / Mortgage Company / Mortgage Broker: %
Developer / Investor / Syndicator / Relocation Company %
Other (explain) %

Yes No

Yes No

Yes No

Yes No

Narrative Checklist Verbal


Yes No

**Membership in a professional association can reduce your premium.

None
Yes No

**A formal risk management or continuing education program can reduce your premium.

Organization of Real Estate Professionals (OREP)

6760 University Ave, Suite #250, San Diego, CA 92115

Phone: (888) 347-5273 * Fax: (619) 704-0567 or (619) 269-3884

email: inspectors@orep.org * www.orep.org

David Brauner Insurance Services Calif. Lic. #0C89873

OREP-Organization of Real Estate Professionals Insurance Services, LLC

Calif. Lic. 0K99465

Home Inspector Professional Liability (E&O) Insurance Application

Page 2

CURRENT INSURANCE INFORMATION


Yes No

Yes No

Yes No


Yes No
Insurance Company Expiration Date Limit of Liability Retention/Deductible Premium
$ $ $
$ $ $
$ $ $


$100,000 / $300,000
$300,000 / $300,000
$500,000 / $500,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000

$2,500 Each claim
$5,000 Each claim

Many coverages can be added at no cost, but coverages will only be added if requested by insured on the application. Please check the boxes for any desired coverages.


Pool & Spa Inspection
(Requires Proof of Training/Certification, No Additional Premium)
Additional Limit for claims Expenses (?)
Mortage Field Inspection
Mold Inspections
(Requires Proof of Training/Certification, Additional Premium Applies)
Water and Air quality testing
(No Additional Premium)
Septic Inspections
(Requires Proof of Training/Certification, Additional Premium Applies)
Energy Rating
(No Additional Premium)
Referral
Lead Paint Inspections
Exterior Insulation Finish Systems (EIFS) Inspections
Green Building Inspections
Wind Mitigation Inspections
General Liability
Radon Inspection Liability
Termite / WDI Liability
Infrared Thermal Inspections
Commercial
(Under 25% commercial included for no additional premium)

Yes No

Organization of Real Estate Professionals (OREP)

6760 University Ave, Suite #250, San Diego, CA 92115

Phone: (888) 347-5273 * Fax: (619) 704-0567 or (619) 269-3884

email: inspectors@orep.org * www.orep.org

David Brauner Insurance Services Calif. Lic. #0C89873

OREP-Organization of Real Estate Professionals Insurance Services, LLC

Calif. Lic. 0K99465

Hanover Professionals Portfolio

Home Inspector Professional Liability (E&O) Insurance Application

Page 3

LOSS INFORMATION


Yes No

Yes No

Yes No
Details Covered by insurance Total paid for Defense (including insured amounts) Total paid for damages (including insured amounts) Corrective procedure implemented

DECLARATIONS AND NOTICE

NOTICE TO APPLICANT


  • If any of the Applicants discover or become aware of any significant change in the condition of the Applicant's Organization between the date of this Application and the policy inception date, which would render the Application inaccurate or incomplete, notice of such change will be reported in writing to us immediately;
  • Any policy issued, will be in reliance upon the truthfulness of the information provided in this Application; provided, however, with respect to such information, no knowledge or information possessed by any Applicant shall be imputed to any other Applicants. If any person or persons knew as of the policy inception date that such information contained in the Application(s) was untrue, inaccurate or incomplete, then coverage may be denied or canceled if such information was material to issuance of the policy. However, if the Chairperson of the Board of Directors, President, Chief Executive Officer, or Executive Director of the Applicant knew as of the policy inception date that such information contained in the Application(s) was untrue, inaccurate or incomplete, then coverage may be denied or canceled if such information was material to issuance of the policy;
  • Statements in the Application, facts pertaining to or knowledge possessed by the individual signing the Application shall be imputed to the Applicant; and
  • The signing of this Application does not bind the undersigned to purchase insurance.





This Application must be signed by a representative of the Applicant acting as the authorized representative of the person(s) and entity(ies) proposed for this insurance.

Date

(Date)

Signature/Title

(Chief Executive Officer, President, Chief Financial Officer, Managing Partner or Owner)

OREP

Phone: (888) 347-5273 (toll free)

Fax: (619) 704-0567 or (619) 269-3884

Email: inspectors@orep.org

David Brauner/David Brauner Insurance Services Calif. Lic. #0C89873

Important Reminders

  • 1. Please remember to include a copy of your pre-inspection agreement and a summary of your experience and training. Construction trades, please submit a summary of experience, training, education, licensing and certification.
  • 2. If you are currently insured, please include a copy of your existing Declarations Page for Prior Acts coverage.
  • 3. Confirmation of receipt of the package is typically sent same business day by OREP. If you don't receive confirmation, please follow up to verify receipt of your application package by OREP.
Produced By: Agency:OREP-Organization of Real Estate Professionals Insurance Services, LCC. Calif. Lic. #0K99465.

A POLICY CANNOT BE ISSUED UNLESS THE APPLICATION IS PROPERLY SIGNED AND DATED.

NOTICE TO ARIZONA AND MISSOURI APPLICANTS: Claim Expenses are Inside the Policy Limits. All claim expenses shall first be subtracted from the limit of liability, with the remainder, if any, being the amount available to pay for damages.

NOTICE TO ARKANSAS, LOUISIANA AND WEST VIRGINIA APPLICANTS: 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.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provide false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

NOTICE TO IDAHO AND OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

NOTICE TO MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

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

NOTICE TO MICHIGAN AND MINNESOTA APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime and subjects the person to criminal and civil penalties.

NOTICE TO NEW JERSEY APPLICANTS: Any person who knowingly includes any false or misleading information on an application for an insurance policy or files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO AND RHODE ISLAND APPLICANTS: 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 civil fines and criminal penalties.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud any insurance company: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.