VENDOR REGISTRATION

* denotes required fields

CONTACT INFORMATION

Last Name:

First Name:

Company Name:

* Address:

* Zip Code:

* City:

* State:

Email:

Home Phone:

Cell Phone:

Fax Number:

PERSONAL INFORMATION

* Do you have a general liability policy in place?

YES     NO

* Have you been convicted of a felony or DUI within the past seven years? (Do not include convictions that have been sealed, expunged or statutorily eradicated.)

YES     NO

If yes, give date, place, offense, and outcome.

* How did you hear about Index Research Services, Inc.?

Experience

* Do you have any insurance inspection experience?

YES     NO

If yes, please list the companies that you have completed inspections for in the past, both insurance companies and/or field survey companies:

* Are you currently providing inspection services to other companies?

YES     NO

If yes, please list the companies.

LICENSES OR SPECIAL TRAINING

Licensed Home Inspector

YES     NO

Licensed Appraiser

YES     NO

Licensed Realtor

YES     NO

OTHER FIELD SERVICES

Mortgage/Bank Inspections

YES     NO

Claims

YES     NO

Commercial Lines Inspections

YES     NO

EQUIPMENT

* Do you have access to a PC?

YES     NO

* Do you have high speed internet access?

YES     NO

* Do you have a mapping program or software?

YES     NO

* Do you currently have a cell phone?

YES     NO

* Do you currently have reliable transportation?

YES     NO

* Do you have or are you willing to purchase?

Measuring Wheel or other type of measuring device
Digital Camera

AVAILABILITY

* When are you able to completing surveys?

* What mileage radius from your home seed point are you able to cover?

* Please provide a list of cities and/or counties you are willing to cover

    
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