Fillable Form 1.: REAL ESTATE AGENT/BROKER ERRORS & OMISSIONS (Risk Placement Services, Inc.)

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Form 1.: REAL ESTATE AGENT/BROKER ERRORS & OMISSIONS (Risk Placement Services, Inc.)

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REAL ESTATE AGENT/BROKER
ERRORS & OMISSIONS APPLICATION
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY. PLEASE
READ YOUR
POLICY CAREFULLY.
1.
Name of Applicant:
A
ddress:
* List complete addresses of all additional offices on a separate sheet; if none, check here
Contact Name
:
Phone #: Fax #:
Web address:
2. Date Busin
ess was established:
Date Applicant was licensed as a Broker:
Date Applican
t was licensed as an Agent:
3. Is the applicant a:
Corporation:
Partnership: Sole Proprietorship: Independent Contractor:
4. Is applicant
applying for coverage as a: Firm:
Individual:
If
individual are you the Broker/Owner? Yes
No
5. Has Applicant or its Pred
ecessor Firm at any time in the past or present engaged in any business venture outside the
scope of a Real Estate Organization, including but not limited to, construction, property development, mortgage
banking, mortgage brokering or insurance?
Yes
No
If “Yes,” please answer the following questions:
a.Please advise details:
b. Has more than 10% of you
r real estate firm’s income been derived from property development Yes
No
or con
struction activities?
c. Do you under
stand that there is NO coverage under the proposed policy for Loss or Defense Yes
No
costs in connection with claims involving the construction, development, sale or resale of real
property developed or constructed by any applicant?
6. Total number
for each category (list each person only once, identifying their primary area of responsibility).
Full Time Part Time
(1)
Real Estate Agents/Brokers/Independent Contractors
(2)
Property Managers
(3)
Appraisers
(4)
Mortgage Brokers
(5)
Realtor Assistants
(6)
Clerical
(7)
Other (Please describe: )
(8) TOTAL
EO.APP Page 1 of 3 7-03
EO.APP Page 2 of 3 7-03
7.
Applicant’s Gross Revenue for the past 12 months (all fees and commissions before expenses, in
cluding any fees,
commission
s, or bonuses payable to employees and independent contractors). Indicate gross revenue de
rived from
the s
ale of property, NOT the value of properties
sold.
Description Gross Income Number of Projected Income Estimated # of
Last 12 Months Transactions Next 12 Months Transactions
(
for last year)
(
for current yr.)
Resid
ential (Including owned farms) * $
$
Commercial (Including residential
$
$
Properties over 4 units)
Property Man
agement Fees
Residential * $
$
Commercial
$
$
Real Estate Appraisal Fees (complete $
$
Addendum if over 35%)
Residential *
$
$
Commercial
$
$
Mortgage
Brokers $
$
Other (Describe) $
$
TOTAL $
$
*
Residential Real Estate means any property containing a single-family dwelling or multiple-family dwellin
gs of up to 4
units. A
ny properties with more than 4 units are considered comm
ercial.
8.
Percentage of Home Warranties sold on all transact
ions in the past 12 months:
9.
For the past 12 months, please provide the following sale information for each classification (If new in
business,
please provide an estimate for the coming year):
Average
Valu
e Maximum
Val
ue
Resid
ential Properties $
$
Commercial P
roperties $
$
10. Is more than 10% of applicant’s commission income derived from the sale of real estate at any Yes No
one loca
tion or development?
If “Yes,” please advise details on separate sheet.
11.
Does your firm have an in house Policy
Procedures Manual?
Yes
No
12.
Has the applicant or any past or present staff member had their license revoked, or been sub
ject
Yes
No
to disciplinary action by any Real Estate Association, State Licensing Board or other regulatory body?
If “Yes,” please provide details of the relationship including the percentage of gross revenue derived from these sales:
13. Current Insurance
E & O Insurance Co. Policy Period Limit of Liability Retro Date Premium Deductible
a.
b.
How many years has an E&O policy been in place without any lapses in covera
ge?
c.
Has the applicant ever purchased an extended reporting period endorsement? Yes
No
If “Yes,” please explain on a separate sheet.
d. During the past five years has any insurance carrier declined, cancelled or refused renewal of similar insura
nce on
behalf of thi
s applicant, predecessor firm or anyone for whom this insurance will apply? Yes
No
If “Yes,” please explain:
EO.APP Page 3 of 3 7-03
14.
Please check your requested limits, deductible, prior acts date, and
effective date:
Limit:
100/100 250/250 500/500 1/1 other _______
Deductibles: $5000________ $10,000_______ other________
Prior Acts date:
Effective date:
If you are r
equesting prior acts coverage, you must currently have coverage in place matching this
requested date. Please provide a copy of your current E&O Insurance Declarations page.
15.
Does your firm maintain General Liability Insurance? Yes
No
16.
Is the applicant or anyone for whom this insurance will apply awar
e of any:
a.
Professional Liability claim made against them in the past 5 years? Yes
No
b.
Fact, circumstance, situation, act or omission which might reasonably be expec
ted to be
Yes
No
the basi
s of a claim or suit ag
ainst them?
If “
Yes,” to any of 16 (a) or (b) please complete the Supplemental Claim Form.
The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. The undersigned further declares
that any occurrence or event taking place prior to the effective date to the insurance applied for which may render inaccurate, untrue or incomplete any
statement made will immediately be reported in writing to the Insurer and the Insurer may withdraw or modify any outstanding quotations and/or
authorization or agreement to bind the insurance. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in
connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any
investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not stop the Insurer from relying on any statement in this
Application. The signing of this application does not bind the undersigned to purchase the insurance, nor does the review of this Application bind the
insurance company to issue a policy. It is understood the Insurer is relying on this Application in the event the Policy is issued. It is agreed that this
Application shall be the basis of the contract should a policy be issued and it will be attached and become a part of the policy.
* Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insuranc
e or statement of claim containing any materially false information, or conceals for the purpose of misleading
,
informati
on concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to
a
civil penalty or fine.
* not applicable in all states
Signature of the applicant of
Insured:
Must be signed by a Principal Partner or Officer of the Firm
Date:
click to sign
signature
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ERRORS & OMISSIO
NS SUPPLEMENTAL CLAIM APPLICATION
INSTRUCTIONS:
1. This form is to be completed when the Applicant has been involved in any claim or is aware of an incident which
may give rise to a cl
aim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT.
2. If space i
s insufficient to answer any questions fully, attach a separate sheet.
3. In lieu of attaching suit papers, please
provide a complete narrative description of the litigation and facts involved.
1
.Full name of Applicant:
2.
Full name of Individual(s) or firm involved in the clai
m:
3
.Full name of Claimant:
4. Indicate whether: CLAIM SUI
T ACT, ERROR OR OMISSION ONLY (No Claim or Suit)
5.
Date and location of alleged act, erro
r or omission:
6. Date of cl
ai
m:
Date reported to Insurance Company:
7
.Additional defendants
8. IF CLOSED:
Total paid inc
luding deductible(s) For the loss amount? $ _
For defen
se costs $
Indicate whether: COURT JUDGEMEN
T (or) OUT OF COURT SETTLEMENT
Date closed:
9. IF PENDING:
Claimant’
s settlement demand? $
Defendant’
s offer for settlement? $
Insurer’s l
oss for loss & defense? $ /
10. Name(s) of Insurer(s) responding to this claim or incident.
Policy Number:
Limits of Li
ability:
Deductible:
11.
Provide narrative description of suit, claim or incident, including the allegations involved, the potential size
of injury
and your re
sponse
:
_______________________________________________________________________________
12. Explain what action(s) have been taken to prevent reoccurrence of a similar claim:
_____ A. Was
Contrac
t used?
No Yes
I declare t
hat the information submitted herein is true to the best of my knowledge and becomes a part of my Professional Liability
Application. I understand that an incorrect or incomplete statement could void my protection.
____________________________________________________________________________________
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm.)
* Any person
who knowingly and with intent to defraud any insurance company or other pers
on files an
application f
or insurance or statement of claim containing any materially false information, or conceals for th
e
purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent
insuranc
e act, and may be subject to a civil penalty or
fine.
* not applicable in all states
E&O-Claim Page 1 of 1 5-2003
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Form 1.: REAL ESTATE AGENTBROKER ERRORS & OMISSIONS (Risk Placement Services, Inc.)

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Completed 30 July 2020

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