• NOTICE: This is an application for a “Claims-Made” policy. Coverage for prior acts and claims made after termination of this policy may be restricted.
    Please read the policy carefully.

  • (Company name including all dba’s or trade names if applicable)

  • General Information

  • c. Number of years owner licensed as an agent:

  • as a broker:

  • as an appraiser:

  • If Yes, Please provide the name of the entity(s) and the nature of the relationship:

  • 4. During the past 5 years:

  • If Yes, please complete the Purchase / Merger Supplement

  • If Yes, provide details on a separate sheet.

  • If Yes, provide details on a separate sheet.

  • If Yes, provide details on a separate sheet, including the percent (%) of total gross revenues from each state or country.

  • If Yes, what is/was the percentage of the gross commission income derived from these services?

  • 5. Indicate the total number of :

  • * Professionals are defined as: Owners, Partners, Officers, Real Estate Brokers/Agents/Salespersons, Appraisers, Property Managers, Consultants or Auctioneers including independent contractors. Part time is $25,000 or less in annual commission income.

  • Revenue

  • 9. Provide the firm’s gross revenues from the last fiscal year. If newly established, please provide an estimate of revenues for the current annual period (Gross
    revenues are defined as all fees and commissions before expenses):

  • Total # of Transactions

  • Revenue for the 12 months
    Prior to the last Fiscal Year

  • Residential:
  • Sales & Leasing
  • Agent/Broker Owned Property Sales
  • Land and Lots
  • Broker Price Opinions
  • Commercial:
  • Sales & Leasing
  • Agent/Broker Owned Property Sales
  • Land and Lots
  • Farm Land / Ranch Sales
  • Other Services:
  • Appraisals*
  • Property Management*
  • Business Brokering*
  • Auctioneering*
  • Mortgage Brokering*
  • Construction / Development*
  • Consulting / Counseling*
  • Other Real Estate Services*
  • TOTAL:

  • *If the Applicant has revenue derived from any “Other Services” listed above, please complete the Other Services Supplement

  • Risk Management

  • 10. Does the Applicant use approved board of REALTORS® or state association of REALTORS® standard contract forms for the listing and sale
    of all real estate? If No, please explain

  • 11. Does the Applicant have documented procedures which include instructions on how to handle
    complaints and compliance with Federal, State and local statutes?
  • 12. What percentage of transactions involve acting as:
  • 13. Is a written Agency Disclosure Statement used in all transactions and provided to the client?
  • 14. What percentage of residential transactions included
  • 16. Please list the 3 largest sales in the past 3 years:

  • If Yes, what is the percentage of gross commission income derived from

  • hotels/motels?

  • 19. During the past 3 years:
  • If Yes, provide details on a separate sheet
  • 20. After inquiry, is the Applicant, or anyone to whom this insurance will apply, aware of any:
  • b. Act or omissions in the performance of professional service for others which might reasonably be expected to be the basis of
    a claim or suit against them?
  • If Yes to any part of question 20, please complete the Claim / Disciplinary Action Supplement
    IMPORTANT NOTE: The applicant’s disclosure of claim information does not indicate nor imply, in any way, that any act or omission is covered by this policy. In addition, circumstances or incidents that might reasonably be expected to be the basis of a claim MUST be reported to the applicant’s current insurer before the claim reporting period expires
    QUESTIONS 21-23 MUST BE COMPLETED BY NEW BUSINESS APPLICANTS ONLY
  • 21. Notice to Missouri Residents: This question does not apply During the past 5 years has any insurance carrier declined, canceled or refused renewal of similar insurance on behalf of this applicant or anyone to whom this insurance will apply (Other than due to loss of market)?
    If Yes, provide details on a separate sheet and include the date, carrier and reason
  • 22. List Previous Professional Liability Coverage policies this individual, firm or predecessors of firm have held within the last 5
    years. If no insurance was in effect for a given year, state “none” where applicable below:

  • Company

    Policy Period

    Limit of Liability

    Deductible

    Premium

    Retro Date

  • 23. Has the applicant ever purchased an extended reporting period endorsement?
  • If Yes, please provide details to include the date, carrier and reason:

  • Coverage Selection



  • FRAUD WARNING: 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.


    ARKANSAS, LOUISIANA AND WEST VIRGINIA FRAUD WARNING: 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.


    COLORADO FRAUD WARNING: 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 benefits, and/or
    civil damages. In Colorado, any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
    facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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.


    D.C. FRAUD 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.


    FLORIDA FRAUD WARNING: 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.


    KANSAS FRAUD WARNING: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or
    belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile,
    magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance
    policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
    which such person knows to contain materially false information concerning any fact material thereto; 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.


    KENTUCKY FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other 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 insurance act, which is a crime.


    MAINE FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
    defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.


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


    MINNESOTA FRAUD WARNING: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer
    is guilty of a crime.


    NEW JERSEY FRAUD WARNING: Any person who includes any false or misleading information on an application for an insurance policy is subject to
    criminal and civil penalties.


    NEW MEXICO FRAUD WARNING: 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.


    NEW YORK FRAUD WARNING: 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 shall also be subject to a civil penalty not to exceed five thousand
    dollars and the stated value of the claim for each such violation.


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


    OKLAHOMA APPLICANTS FRAUD WARNING: Warning: 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.


    OREGON FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application
    for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
    thereto may be guilty of a fraudulent insurance act, which may subject such person to prosecution for insurance fraud.


    PENNSYLVANIA FRAUD WARNING: 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.


    TENNESSEE FRAUD WARNING: 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.


    VIRGINIA AND WASHINGTON FRAUD WARNING: 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.


    VERMONT FRAUD WARNING: 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.



  • COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING
    COVERAGE AND POLICY ISSUANCE. THE APPLICANT AND FIRM ACCEPTS NOTICE THAT ANY POLICY ISSUED WILL APPLY ON A “CLAIMS-MADE” BASIS.
    THE APPLICANT AND FIRM ACCEPTS NOTICE THAT THEY ARE REQUIRED TO PROVIDE WRITTEN NOTIFICATION TO THE COMPANY OF ANY CHANGES TO
    THIS APPLICATION THAT MAY HAPPEN BETWEEN THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE. THE APPLICATION MUST BE
    SIGNED BY AN ACTIVE OWNER, PARTNER, PRINCIPAL, OFFICER, OR MEMBER OF THE APPLICANT.



    The undersigned is authorized by, and acting on behalf of, the Applicant and represents that all statements and particulars herein are true,
    complete and accurate and that there has been no suppression or misstatements of fact and agrees that this application shall be the basis of,
    and becomes part of, the Applicant’s Real Estate professional liability coverage

  • Print Name
  • Title

  • Signature:

  • Date


  • Signature:


  • Please complete only the sections that apply to services performed by the Applicant or Insured

  • Real Estate Appraisal Services

  • 1. Complete the following for each owner or appraiser performing services on behalf of the Applicant (use separate sheet if needed):

  • Name

    Year Licensed
    /Certified

    Prof. Designations /
    Certifications

    Years with Firm

    Type

  • 4. Please list the 3 highest value appraisals performed in the past 3 years:
  • 5. Please provide the % of appraisal revenue for each type of appraisal performed in the last fiscal year ( MUST TOTAL 100% ):

  • Type of Appraisal

    % of Revenues for Last
    Fiscal Year

    Type of Appraisal

    % of Revenues for Last
    Fiscal Year

  • Single Family Dwellings
  • Commercial / Industrial Property
  • Multi-Family Dwellings
  • Shopping Center / Retail Store
  • Residential Lots
  • Land Development / Subdivisions
  • Review Appraisals
  • Agriculture / Farm / Ranch
  • Flood Zone Certifications
  • Construction Phase Inspections
  • Estate or Tax Purposes
  • Condemnation / Eminent Domain
  • Right-of-Way

  • Real Estate Auctioneering Services

  • If Yes, in what year did you obtain your license?

  • Property Management Services

  • 9. Please provide a breakdown of the types of properties, ownership and revenues for PM services performed in the last fiscal year:

  • Property Type

    Number of Units / Sq. Ft.

    Gross P.M. Income

    % Ownership (if any)

  • 1-4 Family Residential
  • Apartments/ Condominiums
  • Home Owners Associations
  • Shopping Centers / Warehouses
  • Office Buildings / Commercial

  • Mortgage Brokering Services

  • 3. Indicate the percentage of loans which are:

  • Construction Development / Ownership Interest Services

  • If Yes, please provide the following:

  • 2. For the past 12 months, please provide the amount of gross commission income (GCI) derived from the sale of properties
    associated with the separate business entity described in question 1. above:

  • 3. During the past 5 years has the Applicant or any of its agents:

  • If Yes to part a. of question 3 above, please complete a Claim Supplement for all claims.

    If Yes to part b. of question 3 above, provide details below:

  • Real Estate Consulting / Counseling Services

  • 1. Briefly describe the nature and type of real estate consulting and/or counseling provided by the Applicant within the past year (use a separate sheet if necessary):

  • Business Brokerage Services

  • 1. Please provide the Name and the years of business brokerage experience for each agent or broker who is involved in the sale of business opportunities:

  • Agent or Broker’s Name

    Years of Business Brokering Experience

  • 2. .Is the Applicant, or the agent or broker responsible for the sale of the business, involved in the valuation of the business being sold?

  • 3. Does the Applicant disclose to the purchaser in writing that there is no certainty or assertion of any future business value or income?

  • Please provide a copy of the standard disclosure form and any other forms, waivers or disclosures used by the Applicant
    during the negotiation and sale of Business Opportunities.

  • 4. Does Applicant provide a written recommendation that each party retain an attorney and an accountant for the purpose of performing a due diligence review; including evaluation of the income, expenses and feasibility of the sale/purchase of the business operations?

  • 5. Does Applicant have a written policy prohibiting agency personnel from making recommendations regarding attorneys

    and accountants selected?

  • 6. Briefly describe the number and types of Business Opportunities arranged, negotiated or sold by the Applicant within the past

    three years (use a separate sheet if necessary):

  • Other Real Estate Services

  • 1. Briefly describe the nature and type of other real estate related services provided by the Applicant within the past year (use a separate sheet if necessary):

  • FRAUD WARNING: 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 penalties.

    FLORIDA FRAUD WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or
    insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any
    an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

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

  • I understand that the information submitted in this supplement becomes a part of my Real Estate Professional Liability Insurance
    application and is subject to the same representations and conditions.

  • Print Name
  • Title

  • Signature:

  • Date

  • Signature: