Fillable REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE APPLICATION

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REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE APPLICATION

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JPP-NB
-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 1 of 7
May not be copied without permission.
REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS 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:
Street Address:
Mailing Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Contact Name:
E-mail & Website:
1.
List all states in which the applicant operates and the percentage of
revenue for each state:
2.
Year firm established:
3.
as broker:
(If firm has been established less than 3 years, please submit a copy of the principal broker’s resume.)
4.
Is applicant a(n):
Individual
Partnership
Corporation
LLP
LLC
5.
Is the applicant owned, controlled by, or affiliated with any other entity? (If yes, please
attach details on a separate sheet) (Do not include Franchise affiliation information.)
Yes No
6.
During the past 5 years:
A. Has the applicant been involved in any merger, acquisition, or consolidation? (If yes,
please attach details on a separate sheet. Please include any firm name
changes.)
Yes No
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? (If yes, please attach a detailed explanation on a separate
sheet.)
Yes No
7.
Does the applicant perform or intend to perform professional services for REITS or property
syndications? If yes, what is the percentage of the gross commission income derived from
these services? %
Yes No
EO-XL-NB-APP
JP
P-NB-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 2 of 7
May not be copied without permission.
Insurance Agent
Information
Name
Agent License Number
Return to:
Pearl Insurance phone 800.289.8170
1200 East Glen Ave. fax 309.688.5820
Peoria Heights, IL 61616
8.
Real Estate Services: Please indicate the Applicant’s total gross commission income or fees derived from
each of the following real estate services.
Please note: Total gross commission income or fees are those which are paid to the Applicant for the
listing or sale of real estate before commission or fees to sales persons representing the applicant firm,
but after commissions or fees to other firms. If new company, please estimate/project commissions
income/fees for the next 12 months.
Last 12 Months
Commissions/Fees
Last 12 Months
# of Transactions
*
If you have commission/fees derived from Appraising, Auctioning, Mortgage Brokering or Property
Management, please complete Other Real Estate Services Supplemental Application.
Estimated Gross Commission Income/Fees for next 12 months: $
Total Gross Commission Income/Fees from previous year
to that reported above:
$
EO-XL-NB-APP
JPP-NB-APP 1119 © 2019
X.L. Insurance America, Inc. All Rights Reserved. Page 3 of 7
May not be copied without permission.
9.
Staff Information: Please list the total number of staff for each of the following: (List each person only once,
identifying their primary area of responsibility)
Agents Earning
More than $20,000
in commission
Agents Earning
Less than $20,000
in commission
No Income
Real Estate Agents/Brokers/Independent
Contractors
REALTOR
®
Assistants (licensed &
unlicensed)
Property Managers
Appraisers
Auctioneers
Mortgage Brokers
Real Estate Consultants
Referral Agents (referring only to applicant)
Clerical
Other (please describe)
TOTAL
Underwriting Information
10. Do at least 15% of all licensees hold a professional designation? (Such as GRI, Broker,
Associate Broker)
Yes No
11.
Have at least 50% of all licensees participated in an accredited real estate continuing
education program?
Yes No
12.
Does the applicant offer a Home Warranty Program to all residential clients?
Yes No
13.
Does the applicant use a standard contract form for the listing and sale of all Real Estate
approved by a board of REALTORS
®
or state association of REALTORS
®
? (If no, please
explain on a separate sheet why nonstandard forms are used.)
Yes No
14.
Does any client represent more than 25% of the applicant’s annual income? (If yes, please
provide details on as separate sheet. Please include: name of the entity, percentage of
revenues from that entity and the expected percentage for the next 12 months.)
Yes No
15.
Do all of the applicant’s brokers and salespersons disclose to their clients, in writing, the legal
nature of their relationship (i. e. whether the salesperson is representing the buyer/seller or
both?)
Yes No
16.
During the last 12 months, what percentage of transactions did the applicant represent
both the buyer and the seller? If a new firm, provide us with the estimated percentage.
%
17.
During the last 12 months, what percentage of transactions was derived from
REO’s/Foreclosures/Short Sales? If a new firm, provide us with the estimated
percentage.
If Question 17 is greater than 0%, does the applicant utilize a neutral third party loss
mitigation service for all REOs/Foreclosures/Short Sale Transactions?
%
Yes No
18.
In the past year, what was the average value of properties sold by applicant?
$
EO-XL-NB-APP
JPP-NB-APP 1119 © 2019 X.
L. Insurance America, Inc. All Rights Reserved. Page 4 of 7
May not be copied without permission.
19.
Does the applicant have a written procedures manual, including procedures on how to
handle complaints and compliance with Federal, State and Local statutes?
Yes No
20.
Does the applicant’s standard contract include wording that recommends the use of
alternative dispute resolution techniques, such as arbitration or mediation, to settle client
disputes?
Yes No
21.
22.
Does the applicant have a formalized training program for all professionals and staff?
Insurance History
Please provide the applicant’s prior Errors and Omissions Insurance history and a copy of
your current policy declarations page.
Yes No
No prior
Insurance
Insurer
Limits of
Liability
Deductible
Premium
Policy Period
Policy
Retroactive
Date (If
applicable)
Current Year
$
$
$
Previous Year 1
$
$
$
Previous Year 2
$
$
$
Previous Year 3
$
$
$
Previous Year 4
$
$
$
23.
Desired limit of insurance:
$
/
$
Each Claim
Aggregate
24.
Desired deductible:
$
(Please attach financial statement for deductibles
$25,000 or higher.)
Each Claim
Note: The applicant’s disclosure of claim information by responding to the following questions does not
indicate nor imply, in any way, that any act or omissions is covered by this policy
25.
During the past 5 years:
A. Have any principals, partners, directors, officers or other professionals been subject
to disciplinary action by any regulatory agency or association or have they ever had
their license revoked or suspended? (If yes, please attach a detailed explanation
on a separate sheet.)
Yes No
B. After inquiry, 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? (If yes, please submit copies of your carrier’s loss reports
for the past 5 years, or if your loss report is not available, for each claim being
reported, complete the claim supplemental form. If any claim is over $10,000,
whether submitting a carrier loss report or not, please complete the claim
supplemental form.)
Yes No
C. Has any similar errors or omissions coverage been cancelled, declined, or non-
renewed? (Not applicable to Missouri applicants.) (If yes, please attach a detailed
explanation on a separate sheet.)
Yes No
26.
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? (
If yes, please complete the claim supplemental form.)
Yes No
27.
If you answered yes to “25.B.”, have these incidents been reported to the applicant’s former
or current insurers.
Yes No
EO-XL-NB-APP
JPP-NB
-APP 1119 © 2019 X.L. Insurance America, Inc. All Rights Reserved. Page 5 of 7
May not be copied without permission.
IMPORTANT
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.
28.
Have you purchased any extended reporting period endorsement or tail coverage? (If yes,
please attach a copy of the endorsement including the effective and expiration
dates.)
Yes No
APPLI
CANT 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.
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.
EO-XL-NB-APP
JPP-NB-APP 1119 © 201
9 X.L. Insurance America, Inc. All Rights Reserved. Page 6 of 7
May not be copied without permission.
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.
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).
EO-XL-NB-APP
JPP-NB-APP 1119 © 2019
X.L. Insurance America, Inc. All Rights Reserved.
May not be copied without permission.
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.
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. 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.
Page 7 of 7
EO-XL-NB-APP
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REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE APPLICATION

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Completed 27 April 2021

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