SPMGA Southern Preferred MGA, Inc.
633 W. Centerville Rd. Ste 321
Garland, TX 75041-5428
214-703-9900 - Fax 214-703-9624
HOME INSPECTORS ERRORS & OMMISIONS APPLICATION
  1. Applicant's name as appears on license  
  2. Business name (Name as you want it to appear on the policy)                 TREC Inspector License #
            
  3. Street Address
    City  State  Zip 
  4. Any branch offices?  Y N If yes attach a complete listing.
  5. Phone  Fax  Email 
  6. Application is Individual  -    Partnership   Corporation   Other
  7. Owner's Listing (Name)                                                 % of ownership    years experience     years licensed
    %
    %
    %
  8. Is applicant engaged in any other business other than Home Inspection? Y   N
    If yes, explain
  9. Is applicant controlled, owned, affiliated or associated with any other firm, agency, Corporation or Insurance Company ? Y   N   
    If yes, explain
  10. During the past 3 years has the name of the Agency been changed or has any other business or Agency been acquired, merged into or consolidated with the applicant? Y   N
    If yes, explain
  11. E & O policy currently in force ? Y   N
    Expiration Date    Retroactive Date   Company 
  12. Has the applicant ever had an E & O policy declined, renewal refused, or canceled?   Y   N
    If yes, explain
  13. What was total gross revenue last year?   $  Projected next year?   $
  14. What was total number of inspections? 
  15. Of that total number of inspections, how many were of a value between
    $0 to $250,000              $250,001 to $500,000              Over $500,000 
  16. How many years do you maintain your files? 
  17. If accepted by the insurer what is the requested effective date? 
  18. Requested limit $/$ Requested deductible $
  19. Has the applicant or any employee of the applicant ever been subject to disciplinary action by any State Agency?
    Y N
  20. Have any claims or suits been made against applicant or any staff member? YN
  21. After inquiry of EACH person proposed for insurance, is the applicant AWARE of any CIRCUMSTANCE, OMISSION, ERROR or OFFENSE which may result in a claim being made against the applicant or any of applicant's employees? Y N
  22. If the answer to 19, 20, or 21 is YES, please explain

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    23. APPLICANT CERTIFICATION

    I certify that I have read the questions above, and have answered each truthfully and completely to the best of my knowledge

    I further herein certify that I understand and agree as follows:

    1. This is a CLAIMS MADE policy form, and any claim or suspected claim must be reported during the policy period for coverage to be in effect.
    2. Each and every loss shall be subject to the DEDUCTIBLE stated in the policy declarations.
    3. Coverage is only in effect for the TYPE OF BUSINESS stated in the declarations.
    4. Any material misrepresentations, failure to disclose material facts, or failure to disclose any pre-existing condition or incident may result in denial of coverage and/or rescission of the policy by the company.
    5. The policy contains EXCLUSIONS for situations not intended for coverage by the company, and it is the responsibility of the applicant to read the policy.
    By placing the initials of the applicant in the box below, the applicant acknowledges acceptance of the above, and understands that the initials carry the effect of a signature.

    Initials Date Name of applicant Title