Fillable Appraisers Errors And Omissions Application (Kinsale Insurance)

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Appraisers Errors And Omissions Application (Kinsale Insurance)

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The Appraisers Errors And Omissions Application (Kinsale Insurance) form is 4 pages long and contains:

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  • 38 check-boxes
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Page 1 of 4
APPRAISERS ERRORS & OMISSIONS APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the
policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities
are not requesting coverage under this policy:
5. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. Has the name or ownership of the entity changed or has any other business been Yes No
purchased, merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or Yes No
control any entity?
12. During the past five years, has your name been changed or has any other business Yes No
purchased, merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact
involved:
13. Please list any associations of which you are a member:
As part of your application, please include a copy of your
appraisal form
including any disclaimers and/or assumptions made as part of
the appraisal.
1. How may licensed appraisers (including trainees) are in the firm?
Please detail the years of experience/qualifications for each appraiser in the firm?
2. Do at least two appraisers review/sign-off on each appraisal? Yes No
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
Please describe any other quality control measures in place:
3. Type & Date of License (e.g. Certified Residential, Cert. Commercial, Cert. General, Trainee, etc.):
List Appraiser Associations of which you are a member:
4. Total Annual Appraisal Income: $
a. Percentage of Income Derived from Residential Appraisals: %
b. Percentage of Income Derived from Commercial Appraisals: %
c. Percentage of Income Derived from Other types of property: %
If “c” above is completed, please provide a narrative description of the type of property:
5. What is the estimated average property value you appraised for residential property? $
6. What is the estimated average property value you appraised for commercial property? $
7. What is the estimated average property value for any “other” type of property appraises? $
8. Do you perform any home/building inspection as part of your services? Yes No
If yes, please provide details:
9. What is the largest property value you appraised during the past 12 months? $
10. Has there been any Claim made or any allegation of wrongdoing against the firm Yes No
or any appraiser during the past 5 years in the rendering of Professional Services?
If Yes, please provide a complete narrative description of the claim & payment/reserve
amounts on a separate sheet of paper.
11. Are you aware of any fact, circumstance, situation, act or omission which might Yes No
reasonably be expected to be the basis of a claim or suit against the firm or any
appraiser?
If Yes, please provide complete details on an extra sheet of paper (including date of
the error, date the claim was made, specific allegations involved, your response to the
claim, current reserve amount or amounts paid if closed).
12. Have you or any of your appraisers ever had a license revoked, limited or canceled Yes No
or been the subject of any complaint?
If Yes, please provide complete details (i.e. dates, allegations involved, action taken in
response, etc.) on an extra sheet of paper.
13. Do you currently carry Professional Liability/Errors & Omissions Insurance covering Yes No
your appraisal activities?
Page 3 of 4
If Yes, please complete the following concerning your expiring coverage:
Retroactive date is: (attach a copy of the Declarations page from your current coverage)
Insurance carrier: Limits:
Deductible__________ Premium_________
Is current carrier willing to renew coverage? Yes No
If No, please provide details:
14. Requested limits of Errors & Omissions Insurance:
$100/$100 $250/$250 $500/$500 $1M/$1M Other:
Requested deductible:
$1,000 $2,500 $5,000 $7,500 $10,000 Other:
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for 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 insurance company files a statement of
claim 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 KENTUCKY APPLICANTS: 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.
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 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.
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.
NOTICE 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.
Page 4 of 4
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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 a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 VIRGINIA 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title: ____________________________________
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date: ____________________________________
Agent/Broker Name: __________________________________________________________________________
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Appraisers Errors And Omissions Application (Kinsale Insurance)

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Completed 15 July 2020

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