PI-PLSP-COMB-003 (02/10) Page 2 of 4 Ed. 02/10
b. A mortgage loan made to any borrower that results in the borrower having:
i. A loan to value ratio (LTV) or a combined loan to value (CLTV) ratio greater than
90;
ii. A debt to income (DTI) ratio of greater than 45/55;
iii. An LTV or CLTV greater than 80 when the DTI exceeds 28/36.
c. A mortgage loan containing a prepayment penalty of more than one year.
8. ORIGINATION - Please check if no origination services are provided. Skip to question 9.
a. First mortgage loans originated during the last twelve (12) months:
Loan Portfolio
Dollar Value Number
1-4 Family: $
Multi-family $
Commercial: $
Other: $
TOTAL:
$
9. Has the Applicant or any companies owned by or related to the Applicant declared bankruptcy
or become insolvent?
Yes
No
10. During the past twelve (12) months, have any allegations been made against the Applicant for
violations of the Truth-In-Lending Act, the Equal Credit Opportunity Act or the Real Estate
Settlement Procedures Act? If yes, provide details.
Yes
No
11. Have any claims, suits, or demands for arbitration been made against the Applicant within the
past five (5) years? If yes, complete a Claim Supplement form for each incident.
Yes
No
12. Are you aware of any act, error, omission or any other circumstance that is or could be a basis
for a claim under the proposed insurance?
Yes
No
If yes, complete a Claim Supplement form for each incident. If the Applicant currently has coverage
in force for the Colorado mortgage broker errors & omissions insurance program with Philadelphia
Insurance Companies and have had no lapse in coverage, you may skip this question.
With regard to questions 10., 11., and 12., it is understood and agreed that if any such claim, act, error,
omission, dispute or circumstance exists, then such claim and/or claims arising from such act, error,
omission, dispute or circumstance is excluded from coverage that may be provided under this proposed
insurance and, further, failure to disclose such claim, act, error, omission, dispute or circumstance may
result in the proposed insurance being void, and/or subject to rescission.
REPRESENTATIONS: I/We affirm that the information contained here and in any addendum is true to the best of
my/our knowledge and that it shall be the basis of the policy of insurance and deemed incorporated therein, should
the Company evidence its acceptance of this application by issuance of a policy. I/We hereby authorize the release
of claim information from any prior insurer to the Company or its representatives.
FRAUD NOTICE STATEMENTS
NOTICE TO 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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.”
