2010 Uniform Mitigation Verification Inspection Form (Page 4 of 4) in pdf

ITIGATION INSPECTIONS MUST BE

CERTIFIED

QUALIFIED INSPECTOR.

BY A

Section 627.711(2), Florida Statutes, provides a listing of individuals who may sign this form.

Qualified Inspector Name:

License Type:

License or Certificate #:

Inspection Company:

Phone:

Qualified Inspector – I hold an active license as a: (check one)

Home inspector licensed under Section 468.8314, Florida Statutes who has completed at least 3 hours of hurricane mitigation

training

approved by the Construction Industry Licensing Board which includes the

completion of a proficiency exam.

Building code inspector certified under Section 468.607, Florida Statutes.

General, building or residential contractor licensed under Section 489.111, Florida Statutes.

Professional engineer licensed under Section 471.015, Florida Statutes.

Professional architect licensed under Section 481.213, Florida Statutes.

Any other individual or entity recognized by the insurer as possessing the necessary qualifications to properly complete a uniform

mitigation verification form pursuant to Section 627.711(2), Florida Statutes.

Individuals other than licensed contractors licensed under Section 489.111, Florida Statutes, or professional

engineer licensed under Section 471.015, Florida Statues, must inspect the structures personally and not through

employees or other persons. Licensees under s.471.015 or s.489.111 may authorize a direct employee who possesses

the requisite skill, knowledge, and experience to conduct a mitigation verification inspection.

I, __________________________ am a qualified inspector and I personally performed the inspection or (licensed

(print name)

contractors and professional engineers only) I had my employee (_____________________) perform the inspection

(print name of inspector)

and I agree to be responsible for his/her work.

Qualified Inspector Signature: ___________________________________ Date: ______________________

An individual or entity who knowingly or through gross negligence provides a false or fraudulent mitigation verification form

is subject to investigation by the Florida Division of Insurance Fraud and may be subject to administrative action by the

appropriate licensing agency or to criminal prosecution. (Section 627.711(4)-(7), Florida Statutes) The Qualified Inspector who

certifies this form shall be directly liable for the misconduct of employees as if the authorized mitigation inspector personally

performed the inspection.

Homeowner to complete: I certify that the named Qualified Inspector or his or her employee did perform

an inspection of the residence identified on this form and that proof of identification was provided to me or my

Authorized Representative.

Signature: ___________________________________ Date: __________________________

An individual or entity who knowingly provides or utters a false or fraudulent mitigation verification form with the intent to

obtain or receive a discount on an insurance premium to which the individual or entity is not entitled commits a misdemeanor

of the first degree. (Section 627.711(7), Florida Statutes)

The definitions on this form are for inspection purposes only and cannot be used to certify any product or construction feature

as offering protection from hurricanes.

Inspectors Initials _____ Property Address_____________________________________________________________

*This verification form is valid for five (5) years provided no material changes have been made to the structure. An insurer at

its expense may require that this form be independently verified before accepting the form as valid.

OIR-B1-1802 (Rev. 02/10) Adopted by Rule 69O-170.0155

Page 4 of 4

2010 Uniform Mitigation Verification Inspection Form Page 4

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