Fillable Real Estate Related Application (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank Real Estate Related Application (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Real Estate Related Application (Kinsale Insurance)

On average this form takes 47 minutes to complete

The Real Estate Related Application (Kinsale Insurance) form is 5 pages long and contains:

  • 1 signature
  • 49 check-boxes
  • 163 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE 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
 
Page 1 of 5
REAL ESTATE RELATED
ERRORS
& OMISSIONS APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. List all the Applicant firm’s personnel. Each individual should be classified in only one category based on their primary
responsibility.
Agents Earning More than
$20,000 in commission
Agents Earning Less than
$20,000 in commission
Real Estate Agents/Brokers/Independent Contractors
REALTOR
®
Assistants (licensed & unlicensed)
Property Managers
Appraisers
Auctioneers
Mortgage Brokers
Real Estate Consultants
Clerical
Other (please describe)
TOTAL
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
2. Please provide the applicant’s total gross commission income or fees from each of the following real estate services.
For a start-up company please provide projections for the next 12 months.
3. If applicable, please provide the following sale information for each classification based on the past 12 months (or on a
projection if new in business):
Classification
Average Value
Maximum Value
% of Sales
Representing
Buyers
% of Sales
Representing
Sellers
% of Dual
Agency
Representation
Residential Properties $
$
% % %
Commercial Properties $
$
% % %
Business Broker $ $ % % %
4. Is more than 10% of the applicant’s commission income derived from the sale of real estate at any Yes No
one location or development?
If “yes”, please provide the percentage involved and a description of the development:
Real Estate Services
Last 12 Months
Commissions/Fees
Last 12 Months
# of Transactions
Next 12 Months
Projected
Commissions &
Fees
Next 12 Months
Projected # of
Transactions
Residential (less than 4 units)
Residential Sales & Leasing
Residential Property Management
(Complete Property Management Supplement)
Residential Appraising
Non-Residential (including residential
w/ more than 4 units)
Commercial Properties Sales & Leasing
Sale of Land (Developed or Undeveloped)
Commercial Property Management
Commercial Appraising
Other Services
Sale of Business Opportunities/Business
Broker
Real Estate Development or Construction
Real Estate Auctioning
Mortgage Broker (If more than $5k in
revenue, please complete the Mortgage
Brokers Supplemental Application)
Real Estate Consulting
(Provide a detailed explanation of
services)
Other (describe on separate sheet)
TOTALS
Page 3 of 5
1. Does the applicant offer a Home Warranty Program to all residential clients? Yes No
2. Does any client represent more than 25% of the applicant’s annual income? Yes No
If “yes”, please provide details including the name of the client, a description of the work performed
and the percentage of revenue from that client):
3. During the past 12 months for what percentage of transactions did the applicant represent both the Yes No
buyer & the seller? If a new firm please provide a projected percentage. %
4. For those transactions involved in # 3 above did you have a signed dual agency disclosure form signed Yes No
by all parties 100% of the time?
If “no”, please explain why not:
5. Does the applicant have an in-house office policy/procedures manual? Yes No
6. Does the applicant form, manage or organize group investments/syndications, including limited or Yes No
general partnerships, corporations or REITs for the purpose of investing in real property?
If “yes”, please provide details:
7. Does the applicant perform work involved with 1031 Exchanges? Yes No
If “yes”, please provide details including the number of transactions each 12 months and how the applicant
ensures legal compliance with 1031 Exchange requirements:
1. Provide your agency’s recent insurance history below.
Insurance Company
Limits Per
Claim/Aggregate
Policy Period
(Month/Day/Year)
Annual Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
2. If you are currently insured for errors & omissions coverage, what is your policy’s retroactive/prior acts date?
(month/day/year) _____/_____/_______ If there is no retroactive date, please check here.
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if the
date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
3. Are you being canceled or non-renewed by your current professional liability carrier? Yes No
If yes, please explain why:
4. Requested limits: $100k/$300k $250k/250k $500k/$500k $1M/$1M $2M/$2M
(other) __________________
Requested deductible: $2,500 $5,000 $10,000 $25,000 Other $
INSURANCE AND LOSS HISTORY
Page 4 of 5
5. After inquiry with each person as appropriate, in the last five (5) years, have any claims been made Yes No
against the person or entity applying for insurance, or any of your past or present partners, officers,
directors, employees or other staff members, or any predecessors in business or against any
corporation that any proposed Insured was formerly employed by, associated with or had an
interest in?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include a
currently valued loss run for each claim.
6. After inquiry with each person as appropriate, are you, or any of your partners, officers, directors, Yes No
agents, brokers or employees, aware of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident which may result in a claim?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
7. After inquiry with each person as appropriate, have any of the applicant’s past or present officers, Yes No
directors, employees or other staff members ever been the subject of any investigation by a Real
Estate Association, State Licensing Board or other regulatory body during the past five (5) years or
ever had a real estate license revoked or suspended?
If “yes”, please provide an explanation of the circumstances and penalty involved. If available,
please provide a copy of the complaint, your response, and a copy of the regulatory body’s decision.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for 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 insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
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 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.
Page 5 of 5
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of
the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a 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 a 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 the person to criminal and civil penalties.
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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date
of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based
upon such changes at our sole discretion.
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 of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
click to sign
signature
click to edit
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

Real Estate Related Application (Kinsale Insurance)

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 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document