Fillable NAV-Standard-App - NAV REL OS SUP _04 17_ - Other Services Supplement

Fill Online, Printable, Fillable, Blank NAV-Standard-App - NAV REL OS SUP _04 17_ - Other Services Supplement Form

Use Fill to complete blank online ORGANIZATION OF REAL ESTATE PROFESSIONALS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

NAV-Standard-App - NAV REL OS SUP _04 17_ - Other Services Supplement

On average this form takes 96 minutes to complete

The NAV-Standard-App - NAV REL OS SUP _04 17_ - Other Services Supplement form is 18 pages long and contains:

  • 1 signature
  • 25 check-boxes
  • 368 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Organization of Real Estate Professionals forms online.

BROWSE ORGANIZATION OF REAL ESTATE PROFESSIONALS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NAV REL NB APP (04 17) Page 1 of 5
Navigators Insurance Company
Real Estate Professionals
Errors and Omissions Insurance Application
NOTICE: This is an application for a “Claims-made” policy. Coverage for prior acts and claims made after termination of this
policy may be restricted. Please read the policy carefully.
1. Name of Applicant ____________________________________________________________________________
(Company name if applicable)
Contact ____________________________________________________________________________________
Principal Street Address _______________________________________________________________________
City ___________________________________________________________ ST ________ Zip __________
Mailing Address __________________________________________________ ST ________ Zip __________
Telephone # ( ______ ) __________________________ Fax # ( ______ ) __________________________
E-Mail Address:______________________________________________________________________________
2. a. Date firm was established: ____________ b. Year current owner assumed management: ______________
c. Number of years owner licensed as an agent __________ as a broker ___________ as an appraiser ___________
3. A
pp
licant ownershi
p
: □ Cor
p
oration/LLC □ Inde
p
endent Contractor □ Sole Pro
p
rietor □ Partnershi
p
/LLP
* Professionals are defined as: Owners, Partners, Officers, Real Estate Brokers/Agents/Salespersons, Appraisers,
Property Managers, Consultants or Auctioneers including independent contractors.
4. a. Indicate the total number of active full time professionals: *______
*Full time professionals are defined as earning more than $20,000.00 in annual income.
b. Indicate the number of active part time professionals: *______
*Part time professionals are defined as earning $20,000.00 or less in annual income.
c. Indicate the total number of support staff: ______ and inactive professionals: ________
5. Does the applicant have a formalized training program for all professionals and staff?
Yes No
6. Indicate the number of professional employees who participated in an accredited, continuing professional education
program during the past 12 months. ________
7. Do at least 15% of all professionals hold a professional designation?
(i.e. GRI, CRS, CRE, ABR, MAI, SRA) Yes No
8. Is the applicant owned, associated, or controlled by any business, investment group or syndication? Yes No
If Yes, Please provide the name of the entity(s) and the nature of the relationship:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
9. a. Has any member of your firm engaged in property construction or development (including renovations)?
Yes No
If Yes, check all that apply and complete 9b:
1. Directly (member of your firm doing work themselves)
2. Through a licensed contractor
3. Through a separate business entity owned by any member of your firm or their spouses
(If you checked option 3, please complete supplemental application)
b. Provide gross commission income derived from the sale of these properties in the past 12 months, and include this total
in “Agent/Broker Owned Property Sales” under question 10 on the next page:
Residential $______________________ Commercial $______________________
Check here if none in the past 12 months
Clear Form
To Submit: Save then email to
appraisers@orep.org;
Fax: 619-704-0793
NAV REL NB APP (04 17) Page 2 of 5
10. Provide your gross revenues for the last 12 months and projected next 12 months. If newly established, please provide an
estimate of revenues for the current annual period (Gross revenues are defined as all fees and commissions before expenses,
including fees, commissions and bonuses payable to employees and independent contractors):
Gross Revenues for
Last 12 months
# of Transaction sides
(closed real estate sales
for last 12 months)
Projected Revenues
for next 12 months
Projected # of
Transaction Sides
RESIDENTIAL
Sales & Leasing $ ________________ ____________ $ ________________ ____________
Agent/ Broker Owned Property Sales $ ________________ ____________ $ ________________ ____________
Farm Land $ ________________ ____________ $ ________________ ____________
Raw Land $ ________________ ____________ $ ________________ ____________
Appraisals* $ ________________ ____________ $ ________________ ____________
COMMERCIAL
Sales & Leasing $ ________________ ____________ $ ________________ ____________
Agent/Broker Owned Property Sales $ ________________ ____________ $ ________________ ____________
Farm Land $ ________________ ____________ $ ________________ ____________
Raw Land $ ________________ ____________ $ ________________ ____________
Appraisals* $ ________________ ____________ $ ________________ ____________
OTHER SERVICES
Property Management* $ ________________ ____________ $ ________________ ____________
Sale of Business Opportunities* $ ________________ ____________ $ ________________ ____________
Mortgage Brokering*
$ ________________ ____________ $ ________________ ____________
Auctioneering (Real Property)*
$ ________________ ____________ $ ________________ ____________
Short term Escrow
(Funds distributed within 1 year)
$ ________________ ____________ $ ________________ ____________
Real Estate Consulting
(provide details below)
$ ________________ ____________ $ ________________ ____________
Other
(Provide details below)
$ ________________ ____________ $ ________________ ____________
*If Applicant has revenue derived from any services denoted by an asterisk, please complete the supplemental application
Details of “Real Estate Consulting” and “Other” from above:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
11. Does the applicant have documented procedures which include instructions on how to handle complaints and compliance with
Federal, State and Local statutes?
Yes No
12. Does the applicant use approved board of REALTORS
®
or state association of REALTORS
®
standard contract forms for the
listing and sale of all Real Estate?
Yes No If No, please explain.
13. In the past year, what was the average value of properties:
a. sold $______________________ or b. appraised (if applicable) $_____________________
14. What percentage of residential transactions included a: a. Signed property disclosure form?_____%
b. Home warranty program?_____% c. Home inspection or written waiver?_____%
15. What percentage of transactions involve acting as a: dual agent____% intermediary____% or transactional broker ____%
NAV REL NB APP (04 17) Page 3 of 5
16. Has any member of your firm been involved in asset or property preservation services including any incidental repair work on
bank owned properties within the last 3 year period?
Yes No
17. Has any member of your firm been involved in property rehabilitation services on bank owned properties within the last 3 year
period?
Yes No
If Yes to question 16 or 17, were all such repairs contracted by you done by a licensed contractor?
Yes No
18. For any bank owned properties where you represent the buyer, do you advise the buyer in writing to have the property
inspected by a licensed and insured home inspector prior to purchase?
Yes No
19. Has any member of your firm engaged in acquiring the properties or deeds of financially distressed homeowners, including
sale – leaseback agreements within the last 3 year period?
Yes No N/A
20. Has the applicant engaged in any eviction services on pre-foreclosed or bank owned properties within the last
3 years?
Yes No
If Yes, was the preparation, filing and service of the eviction complaint and obtaining the eviction judgment
handled by an attorney? Yes No
21. Is any client responsible for more than 25% of the applicant’s annual income? Yes No
If Yes, provide the name, relationship and total revenue from the client.
22. Does the firm perform or intend to perform professional services for REITS or property syndications?
Yes No
If Yes, what is the percentage of the gross commission income derived from these services? _____%
23. During the past 5 years:
a. Has the applicant been involved in any merger, acquisition, or consolidation?
Yes No
If Yes, provide details on a separate sheet and include any name changes for the firm.
b. Has any principal, partner, director, officer, or professional of the applicant performed professional services for any other
business which the applicant has any ownership or managerial interest? Yes No
If Yes, provide details on a separate sheet.
24. Does the applicant transact business in multiple states or outside of the United States?
Yes No
If Yes, provide details on a separate sheet, including the percent (%) of total gross revenues from each state or country.
25. After inquiry, is the applicant, or anyone to whom this insurance will apply, aware of any:
a. Professional Liability claim made against them in the past 5 years? Yes No
b. Act or omissions in the performance of professional service for others which might reasonably be expected to be the
basis of a claim or suit against them?
Yes No
c. Complaint, disciplinary action or investigation by any regulatory authority? Yes No
d. Changes in any claims previously reported on past applications?
Yes No
IMPORTANT NOTE: The applicant’s disclosure of claim information does not indicate nor imply, in any way, that any act or omission is
covered by this policy. In addition, circumstances or incidents that might reasonably be expected to be the basis of a claim MUST be
reported to the applicant’s current insurer before the claim reporting period expires.
NEW BUSINESS APPLICANTS ONLY MUST COMPLETE QUESTIONS 26-28
26. Notice to Missouri Residents: This question does not apply:
During the past 5 years has any insurance carrier declined,
canceled or refused renewal of similar insurance on behalf of this applicant or anyone to whom this insurance will apply (Other
than due to loss of market)?
Yes No If Yes, provide details on a separate sheet and include the date, carrier and reason.
27. List Previous Professional Liability Coverage policies this individual, firm or predecessors of firm have held within the last 5
years. If no insurance was in effect for a given year, state “none” where applicable below:
Company
Policy Period Limit of Liability Deductible Premium Retro Date
___________________ _________ to _________ ______________ ____________ $ ___________ __________
___________________ _________ to _________ ______________ ____________ $ ___________ __________
___________________ _________ to _________ ______________ ____________ $ ___________ __________
___________________ _________ to _________ ______________ ____________ $ ___________ __________
___________________ _________ to _________ ______________ ____________ $ ___________ __________
NAV REL NB APP (04 17) Page 4 of 5
28. Has the applicant ever purchased an extended reporting period endorsement?
Yes No
If Yes, please provide details to include the date, carrier and reason:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
29. Coverage Selection:
a. Limits of Liability: Per Claim __________________ Policy Aggregate __________________
Claims Expense Inside the Limit or Claims Expense Outside the Limit
b. Deductible: ___________________ First Dollar Defense? (for a charge) Yes No
Aggregate Deductible? (for a charge)
Yes No
c. Desired Policy Effective Date: __________/__________/__________
d. Current Policy Retroactive Date: __________/__________/__________ (Attach current Declarations page)
FRAUD WARNING: 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.
ARKANSAS, LOUISIANA AND WEST VIRGINIA FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim fo
r
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.
COLORADO FRAUD WARNING: 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
benefits, and/or civil damages. In Colorado, 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 o
f
Insurance within the Department of Regulatory Agencies.
D.C. FRAUD 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.
FLORIDA FRAUD WARNING: 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.
KANSAS FRAUD WARNING: 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 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 fo
r
payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materiall
y
false information concerning any fact material thereto; 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.
KENTUCKY FRAUD WARNING: 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.
MAINE FRAUD WARNING: 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.
MARYLAND FRAUD WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit o
r
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.
MINNESOTA FRAUD WARNING: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against
an insurer is guilty of a crime.
NEW JERSEY FRAUD WARNING: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
NEW MEXICO FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit o
r
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NEW YORK FRAUD WARNING: 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.
NAV REL NB APP (04 17) Page 5 of 5
OHIO FRAUD WARNING: Any person who, with the 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.
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.
OREGON FRAUD WARNING: 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 to the content of the contract commits a fraudulent insurance act, which may be violating state law and may be subject to prosecution
for insurance fraud.
PENNSYLVANIA FRAUD WARNING: 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.
TENNESSEE FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company fo
r
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
VIRGINIA AND WASHINGTON FRAUD WARNING: 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.
VERMONT FRAUD WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF COMPANY’S QUOTATION IS
REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. THE APPLICANT AND FIRM ACCEPTS NOTICE THAT
ANY POLICY ISSUED WILL APPLY ON A “CLAIMS-MADE” BASIS. THE APPLICANT AND FIRM ACCEPTS NOTICE THAT
THEY ARE REQUIRED TO PROVIDE WRITTEN NOTIFICATION TO THE COMPANY OF ANY CHANGES TO THIS APPLICATION
THAT MAY HAPPEN BETWEEN THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE. THE
APPLICATION MUST BE SIGNED BY AN ACTIVE OWNER, PARTNER, PRINCIPAL, OFFICER, OR MEMBER OF THE
APPLICANT.
The undersigned is authorized by, and acting on behalf of, the Applicant and represents that all statements and
particulars herein are true, complete and accurate and that there has been no suppression or misstatements of fact and
agrees that this application shall be the basis of, and becomes part of, the Applicant’s professional liability coverage.
Please print your name _________________________________________________ Title ___________________________________
Signature____________________________________________________________ Date _________________
For Florida Only:
Insurance Agent/Producer Name __________________________________ Insurance License #_____________________
For Iowa Only:
Insurance Agent Name Required
Agent Name:_____________________________________________________________
For New Hampshire Only:
Insurance Agent Name and Signature Required
Insurance Agent Name:__________________________________ Signature: ______________________________________
David Brauner
David Brauner
David Brauner
E59100
NAV REL OS SUP (04 17) Page 1 of 5
Navigators Insurance Company
Real Estate Professionals
Errors and Omissions Insurance
Application
Other Services Supplement
Full Name of Applicant or Insured:_________________________________________________________________
Please complete only the sections that apply to services performed by the Applicant or Insured
Property Manager Information
1. Does the Applicant enter into a contract with each property owner? Yes No
2. Is a budget prepared for each property managed?
Yes No
3. Are standard management and lease agreements used for all properties?
Yes No
4. Does the Applicant hire licensed contractors to provide services for any managed properties?
Yes No
If Yes, does the applicant require certificates of insurance from each contractor?
Yes No
5. What is the Applicant’s average authority for capital improvements, repairs, etc.? $________________
6. Does the Applicant require liability insurance to be in place for all properties managed?
Yes No
7. Indicate the number of property managers who hold professional designations or certification related to P.M.:
_______________
8. Does the Applicant have ownership interest in any properties managed?
Yes No
9. Please provide a breakdown of the types of properties managed, revenues and ownership interest:
Property Type
Total Number of
Units/Sq. Ft.
% of Property
Management Income
(total must = 100%)
% of Ownership
Interest (if any)
Single Family Homes
# Units:
_________% _________%
1 - 4 Unit Condos/Apartments
# Units:
_________% _________%
5+ Unit Condos/Apartments
# Units:
_________% _________%
Home Owners Associations
# Units:
_________% _________%
Shopping Centers
Sq Ft:
_________% _________%
Office Buildings/ Commercial
Sq Ft:
_________% _________%
Other - Describe Property Types:
_________% _________%
100%
NAV REL OS SUP (04 17) Page 2 of 5
Real Estate Appraiser Information
1. Indicate the number of appraisers who have attained professional designations related to the appraisal
market: _______________
2. Indicate the number of appraisers who have participated in an appraisal related continuing education program in
the past twelve months: ______________
3. Are written agreements between the Applicant and the bank or financial institution in place that outline the duties
of the appraiser and the fees charged for such services?
Yes No
4. Does the Applicant always use standard appraisal forms that comply with USPAP?
Yes No
5. Does the Applicant perform any Right-of-Way appraisals?
Yes No
If Yes, please provide the revenue and number of transactions for the past 12 months:
Last 12 Months of Revenue Number of Transactions
Right-of-Way Appraisals $
Real Estate Auctioneer Information
1. Does the Applicant provide any written guarantee relating to the condition of the properties being
auctioned?
Yes No
2. Does the Applicant always put the properties to be auctioned on display for inspection prior to the
auction? Yes No
3. Auctioning revenue:
Last 12 Months of Revenue Number of Transactions
Auctioning of Real Property
$
Construction/Development Ownership Interest Information
1. Has the Applicant, or any of its agents, sold or listed for sale any properties that were developed or constructed
by a separate business entity owned by the firm, any of its agents or the spouse or domestic partner of an agent
or owner?
Yes No
If Yes, please provide the following:
a. Name of the business entity:
b. Percentage of the business entity owned by the firm or agent: ____
%
c. Percentage of the business entity owned by the spouse of domestic partner: ____
%
d. Number of years the entity has been in business: ____
e. Number of years the entity has operated in the same area: __________
f. Number of years of development/ construction experience key personnel have: _____________
g. Types of properties developed or constructed by the business entity: Residential Commercial
2. For the past 12 months, please provide the amount of gross commission income (GCI) derived from the sale of
properties associated with the separate business entity described in question 2 above:
Residential Property GCI: $ ___________________ Commercial Property GCI: $ __________________
Continue to next page
NAV REL OS SUP (04 17) Page 3 of 5
3. During the past 5 years has the Applicant or any of its agents:
a. Had any claims made against them involving the entity mentioned in question 2a. above?
Yes No
b. Have knowledge of any act or omissions which might reasonably be expected to be the basis of a claim
against them involving the entity mentioned in question 2a. above?
Yes No
If Yes to part a. of question 4 above, please complete a Claim Supplement for all claims.
If Yes to part b. of question 4 above, provide details below:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Business Brokerage Information
This section must be completed if coverage for the sale of Business Opportunities is requested.
All questions must be answered completely.
1. Please provide the Name and the years of business brokerage experience for each agent or broker who
is involved in the sale of business opportunities:
Agent or Broker’s Name Years of Business Brokering Experience
2. Is the Applicant, or the agent or broker responsible for the sale of the business, involved in the valuation of the
business being sold? Yes No
3. Does the Applicant disclose to the purchaser in writing that there is no certainty or assertion of any future
business value or income? Yes No

Please provide a copy of the standard disclosure form and any other forms, waivers or disclosures used
by the Applicant during the negotiation and sale of Business Opportunities.
4. Does Applicant provide a written recommendation that each party retain an attorney and an accountant for the
purpose of performing a due diligence review; including evaluation of the income, expenses and feasibility of the
sale/purchase of the business operations?
Yes No
6. Does Applicant have a written policy prohibiting agency personnel from making recommendations regarding
attorneys and accountants selected? Yes No
7. Briefly describe the number and types of Business Opportunities arranged, negotiated or sold by the Applicant
within the past three years (use a separate sheet if necessary):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
NAV REL OS SUP (04 17) Page 4 of 5
Real Estate Mortgage Broker Information
1. How many years of mortgage brokering experience does the Applicant have? ___________________________
2. In transactions where the Applicant serves as both
the real estate agent/broker and the mortgage broker,
does the Applicant inform the client that they are under no obligation to use the Applicant’s mortgage broker
services?
Yes No
3. State(s) in which mortgage brokering services are provided:__________________________________________
a. Are licenses held in all states where required by law?
Yes No
4. Please provide the following, for the past 12 month period:
a. Average Loan Amount: $_________________
b. Value of Largest Mortgage: $_________________
c. Names of top 3 lenders used:
_________________________________________________________________ % used: _____%
_________________________________________________________________ % used: _____%
_________________________________________________________________ % used: _____%
5. Indicate the percentage of loans which are:
Residential: _________% Commercial: _________% Other: _________%
If Other, please specify:____________________________________________________________
6. What percentage of your loans:
Are subprime (B or C loans): _____% Are Combo Loans: _____%
Are held longer than 30 days: _____% Fund new construction: _____%
Have a Yield Spread Premium: _____% Are reverse mortgages: _____%
Are placed through governmental agencies and Savings & Loans: _____%
7. Have you in the past, or do you now:
a. Perform underwriting duties?
Yes No
b. Provide loan servicing duties?
Yes No
c. Have any discretionary loan making authority? Yes No
d. Solicit investors or use your own capital in loans you broker? Yes No
e. Fund any loans via a warehouse line of credit or other means in your own name?
Yes No
f. Perform appraisals on properties you provided mortgage brokering services for?
Yes No
g. Have a correspondent relationship terminated by an investor? Yes No
h. Close or fund any loans without having advance written commitment from an investor or bank to purchase
the loan?
Yes No
If you answered YES to any of the above, please explain on a separate paper on company letterhead.
8. Have any allegations been made against you for violations of the Truth-In-Lending Act, the Equal Credit
Opportunity Act, or the Real Estate Settlement Procedures Act?
Yes No
If you answered YES, please explain on a separate paper on company letterhead.
NAV REL OS SUP (04 17) Page 5 of 5
FRAUD WARNING: 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.
FLORIDA FRAUD WARNING: 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.
MAINE FRAUD WARNING: 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.
MARYLAND FRAUD WARNING: 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.
OREGON FRAUD WARNING: 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 to the content of the contract commits a fraudulent insurance
act, which may be violating state law and may be subject to prosecution for insurance fraud.
I understand that the information submitted in this supplemental questionnaire becomes a part of my Real
Estate Professionals Errors & Omissions Insurance application and is subject to the same representations
and conditions.
__________________________________________________ _____________________________________
Print Name Title
__________________________________________________ _____________________________________
Signature Date
For Florida Only:
Insurance Agent/Producer Name______________________________ Insurance License #____________________
For New Hampshire Only:
Insurance Agent Name and Signature Required
Insurance Agent Name:______________________________ Signature: _______________________________
David Brauner
David Brauner
E59100
NAV REL CLM SUP #2 (02 11) Page 1 of 2
Navigators Insurance Company
Real Estate Professionals
Errors and Omissions Insurance Application
Claim Supplement
This form must be completed for each claim, suit or incident. All questions must be answered completely.
1. Full Name of Applicant or Insured:____________________________________________________________
2. Full Name of Individuals or Firm involved in the claim: ____________________________________________
3. Full Name of Claimant: ____________________________________________________________________
4. Indicate whether:
Incident Claim / Suit
5. Date you became aware of alleged error: _______________
6. Date reported to your insurance carrier: _______________
7. Name of Insurance company: _______________________________________________________________
8. Additional defendants: _____________________________________________________________________
9. If CLOSED: Indicate date closed: _______________ Total Amount Paid $ _____________________
Of the total amount paid, how much was for legal expenses? $ ________________________
What was your deductible? $ ______________________
!
10. IF PENDING: Please send a copy of the suit papers or answer all questions below.
Claimant's settlement demand: $ ________________________
Defendant's offer for settlement: $ ________________________
Insurer's loss reserve: $ ________________________
Is claim in suit?
Yes No If Yes, amount asked in summons $ _____________________
Limits of Liability $ ___________________________ Deductible $ _____________________
11. Provide a brief description of the claim; indicate the alleged error, description of events leading to the claim,
type and extent of injury or damage alleged and what policies or procedures have been implemented to prevent
a reoccurrence or similar situation (use separate sheets as needed):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
!
NAV REL CLM SUP #2 (02 11) Page 2 of 2
FRAUD WARNING: 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.
FLORIDA FRAUD WARNING: 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.
MAINE FRAUD WARNING: 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.
I understand that the information submitted in this supplement becomes a part of my Real Estate
Professionals Errors & Omissions Insurance application and is subject to the same representations and
conditions.
__________________________________________________ _____________________________________
Print Name Title
__________________________________________________ _____________________________________
Signature Date
For Florida Agents Only:
Agent or Producer Name __________________________________ License #____________________________
For New Hampshire Agents Only:
Agent Name and Signature Required
Agent Name:_______________________________________ Signature: _______________________________
David Brauner
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

NAV-Standard-App - NAV REL OS SUP _04 17_ - Other Services Supplement

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document