01
.
Land and Lots
02
.
Page
03
.
Page
Real Estate Agent/Broker/Mortgage Broker
ONE BEACON STREET
SUITE 03300
BOSTON, MA 02108
202-714-1200
john@professionalliabilityusa.com
NEW BUSINESS APPLICATION – REAL ESTATE MISCELLANEOUS PROFESSIONAL LIABILITY
NOTICE: THIS APPLICATION IS FOR A CLAIMS - MADE AND REPORTED POLICY SUBJECT TO ITS TERMS, THIS POLICY WILL APPLY ONLY TO CLAIMS FIRST MADE AGAINST THE INSUREDS AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD THAT MAY APPLY PLEASE READ THE POLICY CAREFULLY TO DETERMINE RIGHTS, DUTIES, COVERAGE AND COVERAGE
RESTRICTIONS
Whenever used in this Application, the term Applicant shall mean the Named Insured proposed for insurance, and You or Your (s) shall mean the persons, entities and subsidiaries, proposed for insurance unless otherwise stated
1. Full Legal Name of Applicant (include all firm names, franchise affiliations, trading names and DBAs under which theApplicant operates):
Contact Name
Company Name
Physical Address
Mailing address if Different than Physical
Email
Title:
Phone
Website:
Dropdown
LLC
Sole Proprietor
Corporation
LLC
LLP
S-Corp
Independent Contractor
Other
LLC
Other Expaination
3. Has the Applicant ever operated under any other name
Yes
No
If " Yes ", please explain:
4. Are You controlled, affiliated with or owned by any other firm or business enterprise ?
Yes
No
If " Yes ", please explain:
B. GENERAL BUSINESS INFORMATION
5. Date Applicant was established:
6. List all states where professional services are provided:
7. Does the Applicant have any subsidiaries for which coverage is requested ? If " Yes ", please complete the schedule below
Yes
No
Choice 3
Subsidiary Information- Complete for each Subsidiary
Repeatable container
Full Legal Name
Year Started
% Owned
Description of Operations
Add more
IMPORTANT: It is understood and agreed that coverage is not provided for subsidiaries not fully disclosed in response to Question 7. Does the Applicant or any of You, including any Independent Contractors own,manage, or control any other entity, including subsidiary related to the Real Estate Industry ?
Yes
No
C. APPLICANT OPERATIONS
8. Provide the following information for all owners and managers with 5 % or greater ownership interest: (please use a separate sheet for additional owners and managers) Name (must equal 100 %)
Name
Position
% of Ownership
First Year Licensed
Add more
9. How many owners, employees, and independent contractors are performing professional services for the Applicant ?
Full Time:
Part Time
Average years of experience
Real Estate Agents/Brokers/Appraisers
10. a Complete the following chart for each service provided If this is a start - up, please provide projections
Do you want coverage for:
Real Estate Agents/Brokers/Appraisers? If NO, indicate and skip to Mortgage Broker portion
Yes
No
Most Recent 12 Months (Not Fiscal Year)
Residential
Commercial
#of Residential Transactions/Side
Gross Residential Commissions and/or Fees(not Total Sale)
#of Commercial Transactions/Sides
Gross Commerical Commissions and/or Fees(not Total Sales)
Sales
Leasing
Land/Lots
Vacation /Rental
Property Managment
Apprasing
Auctionerring
Broker Price Options
Other
Other Explanation
Other Explanation
10B. Total Gross Commissions & Fees Prior 12 Months:
10 C. Total Gross Commissions & Fees Projected Coming 12 Months:
10 D. Approximate % of Most Recent 12 Months Total Revenue derived from Foreclosures or Short Sales:
10 E. Approximate % of
Your
Foreclosures or Short Sales where
You
represented the Seller
11. Complete the below chart for the most recent 12 months:
Property Type
Average Sale Price
Highest Sale Price
Number of Transactions
> $1 Million
Residential
Commercial
13 Do any of You provide any of the following Services ?
If answers to all are " No " check here
If No to all
13 a. Construction / Development
Yes
No
13 b. Construction Management
Yes
No
13 c. Mortgage Brokering
Yes
No
13 d. Formation/Management of REITS
Yes
No
13 e. Sale/Lease/Mgt. of Time Shares
Yes
No
13 f. Business Brokering
Yes
No
13 g. Condo/Assoc. Management
Yes
No
13 Other
Yes
No
Other Description
13 If " Yes " to any of the above, is separate Errors and Omissions coverage in place for these services ?
Yes
No
14. Does the
Applicant
derive more than 10% of Total Commission from any one development, subdivision, or builder?
Yes
No
15 Approximate % of the
Applicant’s
total revenue from the most recent 12 months was derived from the sale of properties owned in part or in whole by one of
Your
Agents, Brokers, Independent Contractors or the
Applicant
itself?
16 Do any of You sell properties Constructed / Developed by any of Your Agents, Brokers, IndependentContractors (" IC "), the Applicant itself, or Spouses of any Agents, Brokers, ICs ?
Yes
No
17. For the most recent 12 months, what percentage of sales transactions included:
17 A. A signed seller’s disclosure statement
%
17 B. A property inspection
%
Please upload sample contracts for You client and your agents
Delete all uploads
Choose files or drag here
18. Does the
Applicant
18 a Document each file with Your recommendations and client instructions:
Yes
No
18 b. Have written procedures in place to notify management of problem transactions
Yes
No
18 c. Have a written internal policy or procedure manual:
Yes
No
18 d. Use in-house legal counsel, legal counsel on retainer, or a risk manager on retainer?
Yes
No
Next
Save for later
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
01
.
Land and Lots
02
.
Page
03
.
Page
Real Estate Agent/Broker/Mortgage Broker
D. Mortgage Broker
Do you want coverage for Mortgage Broker? If yes, Indicate and answer the questions. If no, indicate and skip section
Yes
No
Name of principal mortgage broker in the firm:
Year first licensed as a mortgage broker:
List mortgage broker association memberships:
Top 3 Lender/Investor clients:
Services rendered: % of your Revenue
Origination
Origination
Underwriting
Servicing
Loan Funding or Warehousing Credit
Soliciting
Repurchasing
New Construction
Existing
Residential
Commercial
Other
For the last 12 months, please provide the following:
Average size loan $
Largest size loan
Total dollar value of loans
Revenue Generated from Loans Last 12 Months
Do you handle sub-prime loans?
Yes
No
Revenue Generated from Loans Next 12 Months
The number of sub-prime loans:
Handled in the past fiscal year
Estimated for the next 12 months
The total value of the sub-prime loans handled:
Handled in the past fiscal year
Estimated for the next 12 months
The total annual revenues to the firm from sub-prime loans:
Handled in the past fiscal year
Estimated for the next 12 months
Does firm loan the firm’s own funds?
Yes
No
Does the firm close or fund loans without having an advance written commitment from an investor or bank to purchase the loans?
Yes
No
If yes, provide details
Does the firm hold funded loans for more than 8 months?
Yes
No
Does the firm have a warehouse line of credit?
Yes
No
If yes, what is the amount?
If yes, what is the average number of years the line of credit has been in place with the current warehouse lenders?
What percentage of loans originated are reviewed by separate quality control personnel?
What percentage of loans originated are for clients who applied over the internet?
What % of loans originated are for clients outside of the state of domicile?
If % is greater than 0%, what % of these services are: through employed personnel
If % is greater than 0%, what % of these services are: through independent
List all states in which the firm provides mortgage services:
Are independent contractors always required to carry errors and omissions coverage?
Yes
No
Does firm provide mortgage loan services for homes that are sold by in-house real estate agents or real estate agentworking for an entity related to the firm or any principal in the firm?
Yes
No
In these transactions, does the real estate agent inform the client that they are under no obligation to use this mortgagebroker’s services?
Yes
No
Describe procedures in place to determine if real estate taxes have been paid.
Does the firm have a fidelity or surety bond?
Yes
No
Does the applicant have written procedures for quality control compliance in:
Truth in Lending
Yes
No
Equal Credit Opportunity Act
Yes
No
Real Estate Settlement Procedures Act
Yes
No
Describe your internal audit practices and procedures (i.e. does the applicant perform internal Audits; which areas of the services are audited; howfrequently are these audits performed, etc.)
Are any external audits performed?
Yes
No
If yes, who performs them and how frequently?
Have there been any complaints or criticisms as a result of an audit in the past 2 years?
Yes
No
If yes, provide details:
Has the applicant ever been rejected for application with an investor/lender or had a correspondent relationship terminated with an Investor/lender?
Yes
No
If Yes, Provide Details
Are duties segregated so that no single individual has both custodial & accounting authority over the applicant’s funds & activities?
Yes
No
Does the applicant perform appraisals on mortgage properties?
Yes
No
Next
Previous
Save for later
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
01
.
Land and Lots
02
.
Page
03
.
Page
Real Estate Agent/Broker/Mortgage Broker
E. INSURANCE INFORMATION
19. Please provide the following information regarding the
Applicant’s
most recent insurance policies. (
Please attach a copy of Your current policy Declarations Page with Your Application)
. If no coverage is currently in-force please indicate with a N/A.
N/A
Insurance Carrier
Expiration Date
Limit of Liability
Deductible
Premium
Prior Insurance. Please provide the Carriers and coverage for the last 5 years.
Insurance Carrier
Expiration Date
Limits
Please select
$100,000/$100,000
$250,000/$250,000
$300,000/$300,000
$500,000/$500,000
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
$2,000,000/$2,000,000
Please select
Deductible
Please select
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000
$50,000
$100,000
Please select
Premium
Add more
Retroactive Date:the Applicant first purchased claims made coverage that has been continuously in - force without interruption)
Retro/Prior Acts Date
Current Declarations Page/Policy
Delete all uploads
Choose files or drag here
20. During the past 5 years, has any professional liability claim or suit ever been made against the Applicant, any predecessor firm or any of the Applicant's current or former professional staff ?
Yes
No
If " Yes ", please indicate how many:
Please submit 5 year loss runs and complete a
Supplemental Claim Form
for each claim
Delete all uploads
Choose files or drag here
21. Does any of the Applicant's professional staff know of any incident, negligent act, error or omission, or other circumstance that could result in a claim or suit against the Applicant or any predecessor firm or any of the Applicant's current or former professional staff ?
Yes
No
If " Yes ", indicate how many:
22. Has any of the Applicant's or a predecessor firm's professional staff ever had their license revoked or suspended or been formerly reprimanded or been the subject of a disciplinary action ? If " Yes ", please provide complete details on a and complete a
Supplemental Claim
Form for each Action
Yes
No
E. REQUESTED COVERAGE
Limits of Liability
$100,000/$100,000
$250,000/$250,000
$250,000/$500,000
$300,000/$300,000
$500,000/$500,000
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
$2,000,000/$2,000,000
$2,000,000/$3,000,000
$3,000,000/$3,000,000
Deductible
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000
Other
Other Deductible
F. DECLARATIONS AND NOTICE
The undersigned, acting on behalf of the
Applicants
, represents that the statements set forth in this Application are true and correct and that thorough efforts were made to obtain requested information from all of
You
to facilitate the proper and accurate completion of this Application.
The undersigned agree that the information provided in this Application and any material submitted herewith are the representations of all of
You
and that they are material and are the basis for issuance of the insurance
Policy
provided by
Us
. The undersigned further agree That the Application and any material submitted herewith shall be considered attached to and a part of the
Policy
. Any material submitted with the Application shall be maintained on file (either electronically or paper) with
Us
.
It is further agreed that: ·
**If any of You discover or become aware of any material change which would render the Application inaccurate or incomplete between the date of this application and the Policy inception date, notice of such change will be reported in writing to Us
**Any Policy issued will be in reliance upon the truthfulness of the information provided in this Application; and ·
**The signing of this Application does not bind the Applicant to purchase insurance.
NOTICE TO ALABAMA APPLICANTS:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO ARIZONA AND MISSOURI APPLICANTS:
Claim Expenses are Inside the Policy Limits. All claim expenses shall first be subtracted from the limit of liability, with the remainder, if any, being the amount available to pay for damages.
NOTICE TO ARKANSAS, LOUISIANA AND WEST VIRGINIA APPLICANTS:
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.
NOTICE TO CALIFORNIA APPLICANTS:
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE TO COLORADO APPLICANTS:
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, and civil damages. 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:
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.
NOTICE TO FLORIDA APPLICANTS:
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.
NOTICE TO HAWAII APPLICANTS:
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO IDAHO AND OKLAHOMA APPLICANTS:
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.
NOTICE TO KANSAS APPLICANTS:
Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by 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.
NOTICE TO KENTUCKY APPLICANTS:
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.
NOTICE TO MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON APPLICANTS:
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.
NOTICE TO MARYLAND APPLICANTS:
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or 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.
NOTICE TO MICHIGAN APPLICANTS:
Any person who knowingly and with intent to defraud an insurance company or another 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 act, which is a crime and subjects the person to criminal and civil penalties.
NOTICE TO NEW JERSEY APPLICANTS:
Any person who knowingly includes any false or misleading information on an application for an insurance policy or files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NOTICE TO NEW HAMPSHIRE APPLICANTS
: 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 and civil damages.
NOTICE TO NEW MEXICO AND RHODE ISLAND APPLICANTS:
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.
NOTICE TO OHIO APPLICANTS:
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OREGON APPLICANTS:
Any person who knowingly and with intent to defraud or solicit another to defraud any insurance company: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.
NOTICE TO PENNSYLVANIA APPLICANTS:
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.
NOTICE TO VERMONT APPLICANTS:
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. This Application must be signed by a representative of the Applicant acting as the authorized representative of the person(s) and entity(ies) proposed for this insurance.
Signature / Title
Clear
Title
Date
MM
/
DD
/
YYYY
(Chief Executive Officer, President, Chief Financial Officer, Managing Partner or Owner)
A POLICY CANNOT BE ISSUED UNLESS THE " APPLICATION " IS PROPERLY SIGNED AND DATED
SUBMIT FORM
Please wait...
Preview Submission
Go Back
Previous
Save for later
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20