Business Errors and Omissions Liability

Real Estate Agents and Brokers
Today's Date: 
NOTICE: This application is for a CLAIMS MADE POLICY. Except as may be otherwise provided herein, the coverage is limited to liability for only those claims which are first made against the insured and reported to the Company during the policy period.
1. Name of Firm:
  Street Address:
  City, State, Zip
2. Date Established:
3. Is the applicant firm a Corporation LLC Partnership Sole Partnership  
4. Is the firm owned by, associated with or controlled by any other business? Yes No
  If Yes, give details.
5. Describe in detail the nature of the professional or business activities for which insurance is desired.
 
6. How long have you been engaged in your current occupation or business?   years.
7. Are you engaged in any other profession or business? Yes No
  If Yes, give details.
8. Provide the number of your staff.
  Partners or Officers Professional/Technical Personnel Support
9. List the qualifications of professonal staff. If in business five years or less attach resumes.
 
10. List membership in professional and/or trade organizations.
 
11. Gross Income estimated for next year. Indicate year in spaces provided $
  Current Year $ Previous Year $
12. Are any changes in the nature or size of the applicant's business anticipated over the next 24 months?  If Yes, explain. Yes No
 
13. Does the applicant subcontract services to others? Yes No
  If Yes, explain what types of services and what percent of your total receipts are subcontracted.
 
  Does the applicant require certificates of professional liability insurance or other financial responsibility? Yes No
14. Does your firm use a written contract or agreement describing the services to be provided? Yes No
15. Have your contracts and procedures been reviewed by a law firm? Yes No
16. Does your firm assume liability for others under contracts utilized? Yes No
17. List your three largest clients during the past year and indicate services performed and approximate
revenue from each:
  Name Services Revenues
 
 
 
18. Provide details of General Liability Insurance in force:
  Company Limit Deductible Policy Term
 
  Does the applicant require certificates of professional liability insurance or other financial responsibility? Yes No
19. Please provide details of Errors and Omissions insurance carried during last three years.
  Company Limit Deductible Premium Policy Term
 
 
 
  Is your expiring policy a CLAIMS MADE POLICY? Yes No
  If Yes, advise Retroactive Date.
20. Give an example of a claim that you intend to have insured under this policy.
 
21. Do you provide services/advice to customers/clients which could in any way be impacted by Year 2000 compliance? Yes No
  If Yes, provide details of the services provided or advice given and the type of exposures arising out of or
impacted by Year 2000 compliance.
 
22. Have you done an assessment of the impact of Year 2000 related issues in your organization? Yes No
  If Yes, describe the assessment in detail. If No, describe in detail why you have not.
Attach sheet providing full details of your answer:
 
23. Describe how you will monitor the Year 2000 compliance of third parties' services that you depend
upon to conduct your business:
 
24. Has any application for Errors and Omissions or similar insurance made on behalf of you or your firm, or present partners, owners, officers, or employees ever been declined, or has any such insurance ever been cancelled or refused renewal? Yes No
  If Yes, give details below or attach an information sheet.
 
25. Have any claims, suits or proceedings been made during the past five years against any of you or your firm, your predecessors in business or against any present partners, owners, officers or employees? Yes No
  If Yes, give details below or attach an information sheet.
 
26. Are any of you aware of any alleged act, circumstance, situation, error or omission which may result in a claim being made against you or any of the persons or firm described? Yes No
  If Yes, give details below or attach an information sheet.
 
27. Limit of Liability requested Deductible
28. Please include with this application the following items:
  A. Current brochure or similar item describing activities or services.
  B. Most recent financial statement or annual report.
  C. Copies of standard contracts for professional or business activities.
29. Indicate total gross income paid to the applicant firm (including its affiliated independent contractors) derived
  from the following activities:
      Total Gross Income Number of Units Sold, Leased, Estimated Gross Income
    Activity Past 12 Months Managed or Appraised for Next 12 Months
  a. Residential Real
Estate Sales
  b. Commercial Real
Estate Sales
  c. Residential Leasing
  d. Commercial Leasing
30. Total number of staff. (Please list each person only once, identifying their primary areas of responsibility.)
  a. Full-time real estate agents/brokers/independent contractors
  b. Part-time real estate agents/brokers/independent contractors
  c. Property Managers
  d. Appraisers
31. Please indicate number of sales people in your firm who maintain a professional designation,
  including broker designation:
32. Does your firm offer a Home Warranty Program to all residential clients? Yes   No
  If yes, whose program is offered?      
33. Do you use standard contract forms approved by a local board of realtors or state
  association of realtors? Yes   No
34. Do you follow documented procedures when handling complaints received form your clients? Yes   No
35. Does your firm always obtain a signed seller disclosure? Yes   No
35a. Do all your brokers and salespersons disclose to their clients in writing the legal nature
  of their relationship, i.e., whether the salesperson is representing the buyer or the seller? Yes   No
36. Have you or any member of the firm (including owners, officers, partners, or employees) been
  reprimanded, cautioned, investigated or been involved in any suit or investigating proceeding
  by any regulatory agency, professional review board or similar body for actual or alleged
  violations arising out of professional activities? Yes   No
37. Do you or any person for whom insurance is being requested have any ownership or
  equity interest in any property held for sale? Yes   No
38. Does the applicant or its employees belong to any professional organizations or associations? Yes   No
  If yes, please list those organizations or associations.
 
38a. What is the criteria for membership?
 
39. Are you or any principal, director, parent, subsidiary or other related organization engaged in:
  a. Real estate development or construction? Yes   No
  b. Mortgage banking? Yes   No
  c. Mortgage brokering? Yes   No
  d. Formation, management or organization of any group investments, syndications,      
    limited or general partnerships or real estate investment trusts? Yes   No
40. Do you understand that the policy, if issued, excludes the activities listed in Question 39? Yes   No
 
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.
 
I / WE HEREBY DECLARE that the above statements and particulars are true and that I/we have not suppressed or misstated any material facts and I/we agree that this application shall be the sole basis of any subsequent contract or insurance with the company. Signature of the application does not bind the Firm or Company to complete the insurance.
 
Application must be signed and dated by principal, partner, officer or director of the firm.
 
 
_________________ _______________________________________________________________________
Date Signature of Applicant Title  
 
PLEASE NOTE: COMPLETION AND SUBMISSION OF THIS APPLICATION IS FOR THE PURPOSE OF SECURING A PREMIUM QUOTATION ONLY. NO COVERAGE WILL BE EFFECTED UNTIL RECEIPT OF WRITTEN INSTRUCTIONS AND PREMIUM PAYMENT. ANY SUBSEQUENT CONTRACT ISSUED WILL BE IN FULL RELIANCE UPON THE STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION AND THIS APPLICATION WILL BE MADE A PART OF THE POLICY. A SIGNED APPLICATION DATED NOT MORE THAN 45 DAYS PRIOR TO THE INCEPTION DATE WILL BE REQUIRED IN THE EVENT COVERAGE IS EFFECTED.
 
AGENT OR BROKER ________________________________________________________________________