Fillable Instant Quote Real Estate E&O Insurance Application

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Instant Quote Real Estate E&O Insurance Application

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  • 15 check-boxes
  • 16 other fields

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JPP-IQ-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 1 of 4
May not be copied without permission.
Instant Quote Real Estate E&O Insurance Application
Company Providing Coverage: Greenwich Insurance Company
Notice:
This is an application for a policy that contains “Claims-made” liability protection. Coverage for
prior acts and claims made after termination of this policy may be restricted. Please read the policy
carefully.
Firm Name:
Principal Broker:
Street Address:
Mailing Address:
City:
State:
Zip Code:
Phone Number:
E-mail & Website:
To be eligible for a binding quote, your responses to questions 1 through 5 must be “NO”.
If you answered “YES” to any of questions 1 through 5, you may still qualify for our Instant Quote pricing.
Please call 800-289-8170 or email EOQuote@pearlinsurance.com and a representative will assist you.
1.
Did the firm derive more than $200,000 in gross commission income during the past 12
months?
1 (a) Does the firm project deriving more than $200,000 in gross commission income during
the next 12 months?
Yes No
Yes No
2.
Does the firm provide services involving commercial real estate sales, property management,
real estate construction development, appraisals, mortgage brokering or business brokering?
Yes No
3.
Does any client represent more than 25% of the applicant’s annual income?
Yes No
4.
During the past 5 years, have any errors and omissions claims been made against the
applicant, or any of their past or present principals, partners, directors, officers, or other
professionals?
Yes No
JPP-IQ-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 2 of 4
May not be copied without permission.
** Select your coverage below and remit all applicable premiums. Premium must be mailed to us within 2 weeks
.
** Coverage is not applicable in all states.
Desired Effective Date: _____/_____/________
Annual Premiums
Per Claim Limit
$1,000
Deductible
$1,500
Deductible
$2,500
Deductible
$5,000
Deductible
$250,000
$530
$505
$470
$395
$500,000
$590
$565
$530
$455
$1,000,000
$655
$630
$595
$520
APPLICANT FRAUD WARNINGS
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
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 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 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.
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 of the third degree.
5.
After inquiry, does the applicant, or any principals, partners, directors, officers or other
professionals have knowledge or information of any circumstance or incident, or any
allegation or contention of any incident, which may result in any claim being made against
them?
Yes No
6.
Does the firm currently maintain real estate errors and omissions insurance? If yes, please
remit a copy of your current Declarations page and Endorsements.
Yes No
JPP-IQ-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 3 of 4
May not be copied without permission.
NOTICE TO KANSAS APPLICANTS: A "fraudulent insurance act" means an act committed by any person who,
knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be
presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse,
facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the
issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other
benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain
materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information
concerning any fact material thereto.
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 MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully 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 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.
NOTICE 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 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 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 such person to criminal and civil penalties.
NOTICE TO PUERTO RICO APPLICANTS: Any person who knowingly and with the intention of defrauding
presents false information in an insurance application, or presents, helps, or causes the presentation of a
fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same
damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not
less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of
imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty
thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it
may be reduced to a minimum of two (2) years.
NOTICE 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.
JPP-IQ-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 4 of 4
May not be copied without permission.
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.
NOTICE TO WASHINGTON 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 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.
NOTICE TO ALL OTHER STATES: Any person who knowingly and willfully presents false information in an application
for insurance may be guilty of insurance fraud and subject to fines and confinement in prison. (In Oregon, the
aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to
penalties).
NOTICE 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 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 five thousand dollars and the stated value
of the claim for each such violation.
The proposed insured affirms that the foregoing information is true and agrees that these applications shall constitute a
part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact
or circumstances shall be grounds to rescind the insurance policy.
DISCLAIMER AND AUTHORIZATION
The applicant represents that the above statements and facts are true and that no material facts have been
suppressed or misstated. 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. The applicant accepts notice that they
are required to provide written notification to the Company of any changes to this application that may occur between
the signature date below and any proposed effective date. 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 hereof.
Applicant:
Title:
Applicant’s
Signature:
Date:
Broker/Owner
Name:
The applicant’s signature will authorize Pearl Insurance to fax the quotation and other policy information to the fax
number listed on Page 1 unless otherwise noted.
No, do not fax.
201481-3-PI-EO-APP-GEN
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Instant Quote Real Estate E&O Insurance Application

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Completed 27 April 2021

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