REE-142-04
Rev. 07/2020
IREC use only
License #:
__________________________
Approved:
__________________________
INDEPENDENT ERRORS & OMISSIONS
INSURANCE CERTIFICATION OF
COVERAGE FOR COMPANY
COMPANY NAME: ___________________________________________________________________________
COMPANY LICENSE NUMBER: _____________________________________________________________
INSURANCE AGENT: ________________________________________ PHONE: _____________________
ADDRESS: ______________________________________________________________________________
INSURANCE COMPANY: ____________________________________ PHONE: ______________________
ADDRESS: ______________________________________________________________________________
POLICY NUMBER: ________________________________________________________________________
POLICY DATES: Eff ective: ___________________________ Expiration: ___________________________
PURCHASE DATE: __________________________ PURCHASE TIME: _____________________________
Coverage Limits: $ __________________________ Per Occurrence: $ ______________________ Aggregate
SPECIFY TYPE OF POLICY:
COMPANY ONLY (no individual licensees)
BROKERAGE (FIRM) This policy covers the company AND all licensees associated with the offi ce.
I hereby certify that the above information is correct. The licensee named is covered for all activities licensed
under Chapter 20, Title 54, Idaho Code, and the above-referenced policy meets the standards and coverage
requirements of Idaho Code 54-2013 and IDAPA 24.37.01.118.
I specifi cally certify that the Insurance Company named above currently maintains an A.M. Best Company rating of
B+ or better, and an A.M. Best Financial Size Category of Class VI or higher, as required by IDAPA 24.37.01.118.01.
It is understood and agreed that the Insurance Company will not terminate, cancel, lapse, fail or refuse to renew
or modify the policy without fi rst providing the Commission and the licensee with thirty (30) days written notice.
SIGNATURE: _____________________________________________ TITLE: ______________________
Insurance Representative
DATE: ______________________
Falsifi cation of this Certifi cation by an insurance representative is punishable under Idaho Code 41-1321.
A real estate licensee who knowingly submits a false Certifi cation is subject to discipline, including but
not limited to suspension or revocation of the license. IDAPA 24.37.01.122.
575 E. Parkcenter Blvd., Suite 180
Boise, Idaho 83706
Offi ce: (208) 334-3285
Fax: (208) 334-2050
licensing@irec.idaho.gov
irec.idaho.gov
This form must be completed by an authorized agent or employee of the
insurance carrier. Altered or partially handwritten forms will not be accepted.
click to sign
signature
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