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APPLICATION FOR PROFESSIONAL LIABILITY INSURAN C E 2. (Risk Placement Services, Inc.)

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REA900 Ed. 01 15 Page 1 of 7
APPLICATION FOR PROFESSIONAL LIABILITY
INSURAN
C
E
This application must be completed by the Licensed Broker or designee on behalf of the firm and signed by an owner, officer, or principal of the firm.
1. Principal Contact: Title:
Address: City: State: Zip Code:
Best# to Reach You: Fax#:
E-Mail:
2. Form of Business Entity: Corporation Sole Proprietorship Partnership LLC
Name of Entity: Lic #
Preferred/DBA:
# of Brokers: # of Agents:
Prof. Designations: (Ex. GRI/CRS)
Does the applicant have multiple sales office locations? ____Yes ____No. If Yes, how many? _____. (Please list the
names and addresses of all additional locations under the same ownership
with the firm given in Question #1 & #2)
3. Requested Effective Date: / / Prior Acts Date: / / (attach current declarations page)
Limits Requested – Per Claim/Aggregate (Check all that apply)
__
__ $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 ____ $3,000,000/$3,000,000 Other:
De
ductible Requested (Check all that apply)
____ $1
,000 ____ $2,500 ____ $5,000 ____ $10,000 ____$20,000 ____$25,000 Other:___________________
4. Has the firm name ever changed or has there ever been any acquisition, consolidation, dissolution, merger or change in
business organization? _____Yes ____No. If y
es, please explain by attachment. (coverage is not provided for any predecessor
firms or prior owners unless approved in writing by the insurance company).
5. Are there any Additional Insured’s needed? (Franshises, e.g.) _____________________________________________
6. Is your firm or any agent/broker/principal engaged in any business enterprise or professional practice with any other firm or
business? _____Yes _____No If yes, please explain by attachment.
7. List real estate errors and omissions insurance policies carried over past 5 years (if applicable):
Policy Start Date
Policy End Date
Carrier Name
Liability Limits
Deductible
Premium
$
$
$
$
$
$
$ $ $
$ $ $
$ $ $
REA900 Ed. 01 15 Page 2 of 7
8. Has any policy for the above entity been declined, cancelled or non-renewed in the past 5 years? ….. YES NO
If yes, please explain by attachment.
9. Has any person proposed for this coverage ever been the subject of a disciplinary action by any real estate association, state
licensing board or other regulatory body as a result of real estate agents or brokers, property managers or real estate appraiser
activities?
YES NO If yes, please attach a detailed explaination.
10. Have any claims been made during the past 5 years against you, any current/past agents, brokers, employees or any
persons propsed for this coverage in connection with the rendering of professional services? YES NO
(If yes, current loss runs are required)
11. Are you or any persons proposed for this coverage aware of any act, error, omission, or other circumstance which
might reasonably be expected to be the basis of a claim or suit against you, or any current/past agents, brokers, employees
or clients in connection with the rendering of professional services? YES NO
(If yes, details are required)
12. List Gross Commission Income (prior to commission split) for past and projected 12 month periods.
ACTIVITY
Be sure to list all revenue for the Entity in #2
(only activities you are seeking coverage for)
(NOT CALENDAR YEAR)
Projected Next 12 Months
Gross Commission
Income
Total Trans
Count Dual as 2
Gross Commission
Income
Total Trans
Count Dual as 2
Residential Real Estate Sales (1-4 Units) $ # $ #
Commercial Real Estate Sales (includes 5+ Units) $ # $ #
Raw, Vacant or Partially Developed Land Sales $ # $ #
Real Estate Counseling/Consul
ti
ng $ # $ #
1-4 Units Real Estate Leasing Fees $ # $ #
5+ Units/Commercial Real Estate Leasing Fees $ # $ #
Residential Real Estate Appraisal $ # $ #
Commercial Real Estate Appraisal $ # $ #
1-4 Units Property Mgt. Fees $ # $ #
5+ Units/Commercial Property Mgt. Fees $ # $ #
Seasonal/Vacation Rental Fees $ # $ #
Mortgage Brokering $ # $ #
Mortgage Banking $ # $ #
Escrow: Broker Held or 3rd Party
$
#
$
#
Business Brokering/Opportunities $ # $ #
Referrals/Broker Price Opinions $ # $ #
Agent or Direct Relative-Owned Property Sales $ # $ #
Other: $ # $ #
TOTAL: $ # $ #
REA900 Ed. 01 15 Page 3 of 7
13. In the last five years, has the applicant engaged in any professional services or business other than those indicated
above? ____Yes ____No. If yes, please describe________________________________________________________
14. What percentage of sales are from new construction?______% If any, are you the exclusive sales agent for a
builder/develovper?_____Yes_____No If yes, please describe________________________________________________
15. What percentage of transactions involve dual agency, in any? __________%
16. During the last 12 months, what % of transactions were REO’s/Foreclosures/Short Sales? __________%
17. Is the applicant involved in property management?____Yes____No. If yes, please complete the following:
Is a budget prepared for each piece of property managed? ____Yes ____No
Is a credit report obtained on each prospective tenant? _____Yes_____No
Do you use standard management and lease agreements?____Yes____No
Number of residential units managed:_____________
Commercial/Industrial units/building managed:
__ _ _res units _ _ __condos __ ___5+ units apts __ __office buildings _____warehouses _____shopping centers
Does the applicant (or anyone who may qualify as an insured) have a combined financial intere
st that exceeds 10% in
any property managed? ____Yes____No
Do you provide property management services for HOA’s? ____Yes____No
18. Does the applicant have an in-house procedures manual? ______Yes_____No
Does the applicant conduct in-house training and/or encourage agents to take outside training courses?__ _Yes_ _No
Does the principal broker have a specific training program for his/her sales associates?__ __Yes__ _No
Has the applicant’s principal broker attended a risk reduction seminar in the last year?__ __Yes__ __No
Are standard contract forms used?__ __Yes __ __No
If yes, what percentage of transactions use standard contract forms?________ %
Are property/seller disclosure forms used?___ _Yes__ __No
If yes, what percentage of transactions use disclosure forms?__ ______ %
Does the applicant require their agents to perform visual inspections of properties?__ ___Yes__ ___No
19. Complete this section ONLY
if requesting coverage for RESIDENTIAL REAL ESTATE BROKERAGE
a. Do you or your agents buy or sell your own properties? YES NO
If yes, How many in the past 12 months ? Anticipated next 12 Months ?
b. Have you ever / do you intend to list a new or conversion condominium project? YES NO
c. Average sale price of residential transactions sold in past 12 months: $
d. Top 3 sales prices from past 12 months:
$ $ $
e. % sales representing: Buyer % Seller % Dual %
f. % of transactions covered by home warranties: % Companies used:
g. % of sales using a transaction coordinator: % Transaction coordinator used:
REA900 Ed. 01 15 Page 4 of 7
20. Complete this section ONLY
if requesting coverage for RESIDENTIAL MORTGAGE BROKERING
a. Average Loan Amount: $ Value of Largest Mortgage: $
b. What percentage of your total loans:
Are Conforming Loans_
Have a Yield Spread Premium_
% Are Construction Loans_
% Are Jumbo Loans_
%
% Are Combo Loans_ %
Are A Loans_
% B Loans_
% C Loans_ %
c. Do any of your activities include:
Perf
orming any underwriting duties? ……………………………………………………………………………. YES NO
Soliciting investors/use of your own capital in loans you broker? …………………………………. YES NO
Holding loans longer than 30 days? ……………………………………………………………………………….. YES NO
Loans via a warehouse line of credit or other means in your own name? …………………….. YES NO
Brokering or funding any commercial loans? …………………………………………………………………. YES NO
Funding loans without having advance written commitment from an investor? ………….. YES NO
Reverse mortgages? …………………………………
……
……………………………………………………………… YES NO
Providing loan-servicing duties? ……………………………………………………………………………………. YES NO
Any non-institutional/private money loans? …………………………………………………………………. YES NO
d. Do you have written procedures for compliance with Truth in Lending, Equal Credit Opportunity Act & Real
Estate Settlement Procedures Act? …………………………………………………………………………………….. YES NO
e. Do you perform audits? ……………………………………………………………………………………………………..… YES NO
f. Have you ever had a correspondent relationship terminated by an investor? …………………….. YES NO
21. Complete this section ONLY
if requesting coverage for COMMERCIAL/LAND BROKERAGE
a. Provide percentages of type of commercial transactions for the past 3 years below: (sum of all must = 100%)
%
Office, Warehouse, or Habitational (5+ units) Leasing/Property Management
%Office, Warehouse, Habitational (5-29 units), Land (Raw, Vacant, or Partially Developed) Sales
%Habitational (30+ units), Research & Development, Industrial/Manufacturing, Entitlement
Operations, or Retail Sales
b. List the 3 highest sale prices in the past 3 years and what type of commercial/land they were:
$ Type/Land Acreage:
$ Type/Land Acreage:
$ Type/Land Acreage:
c. Do you have dedicated agents conducting your commercial transactions? ………………………….. YES NO
d. Does your office employ attorneys to assist with commercial contracts? …………………………….. YES NO
e. What type of commercial transac
ti
ons do you project to have in the next 12 months?
REA900 Ed. 01 15 Page 5 of 7
22. Complete this section ONLY
if requesting coverage for BUSINESS BROKERAGE
a. List the 3 highest sale prices in the past 3 years and what type of business opportunity they were:
$ Type: Including the building? YES NO
$ Type: Including the building? YES NO
$ Type: Including the building? YES NO
b. Type of business opportuni
ti
es involved in/planning on:
c. Do you have dedicated business opportunity agents? …………………………………………………………. YES NO
who?
How many years of business brokerage experience?
Please Read carefully and Sign Below where indicated.
The undersigned proprietor, partner, member or officer, acting on behalf of the applicant and all others to be insured,
hereby,
(A) declares after diligent inquiry that the above statements and particulars are true and that no material facts have
been suppressed or misstated:
(B) acknowledges that it is understood and agreed that (1) the completion of this application does not bind Liberty
Surplus Insurance Corporation to issue nor the Applicant to purchase the insurance; (2) however, this application
will be the basis of the contract if a policy is issued; and (3) all written statements and material furnished to
Liberty Surplus Insurance Corporation in conjunction with this application are hereby incorporated by reference
into this application and made part hereof; and
(C) acknowledges that, in the event Liberty Surplus Insurance Corporation issues a policy, (1) Liberty Surplus
Insurance Corporation in providing coverage will have relied upon, as representations, the declarations and
statements which are contained in or attached to or incorporated into the policy; and (2) in the event of a claim
for which coverage would otherwise be available under this policy, the Applicant will be required to be defended
by lawyers appointed by Liberty Surplus Insurance Corporation and if the Insured elects to handle any claim
without such lawyers or otherwise without Liberty Surplus Insurance Corporation’s involvement, then no
coverage for such claim will be afforded the Applicant under the policy.
N
ame T
itl
e
Si
g
natu
re D
at
e
/
/
NOTE: Early cancellations subject to minimum earned premium up to $750 and/or a short rate charge of 10%
THIS APPLICATION IS FOR QUOTATION PURPOSES ONLY AND DOES NOT BIND THE COMPANY TO ISSUE INSURANCE.
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REA900 Ed. 01 15 Page 6 of 7
FRAUD WARNINGS BY STATE
NOTICE TO ALABAMA 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 ALASKA APPLICANTS: A person who knowingly and with intent to injure, defraud or deceive an insurance company files a
claim containing false, incomplete or misleading information may be prosecuted under state law.
NOTICE TO ARKANSAS 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 ARIZONA APPLICANTS: For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
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.
NOTI
CE 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 im prisonment,
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.
NOTI
CE TO CONNECTICUT 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 DELAWARE APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
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 in the third
degree.
NOTI
CE TO GEORGIA 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 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 APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any Insurance Company,
files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO ILLINOIS 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 INDIANA APPLICANTS: Any person who knowingly and with the intent to defraud an insurer files a statement of claim
containing any false, incomplete or misleading information commits a felony.
NOTI
CE TO IOWA APPLICANTS: Any person who 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 KANSAS APPLICANTS: Any person who knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to fines and imprisonment.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with the 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.
NOTICE TO LOUISIANA 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 MAINE APPLICANTS: It is a crime to provide false, incomplete or misleading information to an insurance company for the
purpose of defraud
ing the Company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND, MASSACHUSSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI AND MONTANA 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 may include imprisonment, fines or a denial of insurance benefits.
REA900 Ed. 01 15 Page 7 of 7
NOTICE TO NORTH CAROLINA APPLICANTS: Any person who knowingly presents false information in an application for insurance is
guilty of a felony and may be subject to fines and imprisonment.
NOTICE TO NORTH DAKOTA 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 NEBRASKA APPLICANTS: Any person who 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 NEW HAMPSHIRE APPLICANTS: Any person who, with purpose to injure, defraud or deceive any Insurance Company,
files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for
insurance fraud, as provided in RSA 638:20.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
NOTI
CE TO NEW MEXICO 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 NEVADA 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 may include imprisonment, fines or a denial of insurance benefits.
NOTI
CE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any Insurance Company or other person
files an application for insurance or statement of claims 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 eac
h such violation.
NOTI
CE 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 OKLAHOMA APPLICANTS: 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.
NOTICE TO OREGON APPLICANTS: It is a crime to knowingly intend to defraud, provide materially false information related to the
acceptance of the risk or provide materially false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with the intent to defraud any Insurance Company or
other person files an application for insurance or statement of claim containing any fact 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.
NOTI
CE TO 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 fines and
confinement in prison.
NOTICE TO SOUTH CAROLINA, SOUTH DAKOTA, TENNESSEE, TEXAS, UTAH, VERMONT, VIRGINIA, WASHINGTON, WISCONSIN AND
WYOMING 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 may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO 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.
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APPLICATION FOR PROFESSIONAL LIABILITY INSURAN C E 2. (Risk Placement Services, Inc.)

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Completed 30 July 2020

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