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RENEWAL APPLICATION
REAL ESTATE RELATED ERRORS & OMISSIONS
1. Current Kinsale policy number:
2. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
_________________________________________________________________________________________________
3. Please list all other business/dba names for which you are seeking coverage under this policy:
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. 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 past 12 months or are any such changes
contemplated for the next 12 months?
If “Yes”, please provide a description of the changes on an attached sheet of paper.
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
Next 12 Months Next 12 Months
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
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2. Please provide the applicant’s total gross commission income or fees from each of the following real estate services.
3. If applicable, please provide the following sale information for each classification based on the past 12 months:
Classification
Average Value
Maximum Value
% of Sales
Representing
Buyers
% of Sales
Representing
Sellers
% of Dual
Agency
Representation
Residential Properties $
$
% % %
Commercial
Properties
$
$
% % %
Business Broker $ $ % % %
4. During the past 12 months, or projected for the next 12 months, did/will more than 10% Yes No
of the applicant’s commission income be derived from the sale of real estate at any
one location or development?
If “yes”, please provide the percentage involved and a description of the development:
Real Estate Services
Next 12 Months Projected
Commissions & Fees
Next 12 Months Projected # of
Transactions
Residential (less than 4 units)
Residential Sales & Leasing
Residential Property Management
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
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5. After inquiry with each person as appropriate, during the last 12 months, have any claims Yes No
been made against the person or entity applying for insurance, or any of your past or
present members, partners, officers, directors, employees, or any predecessors in business?
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, have any new claims/incidents/circumstances Yes No
been reported to any previous carrier including under an extended reporting period?
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. Please provide details of any status changes in previously reported claims including changes in
amounts paid in defense costs or to settle claims.
Please include an updated loss run for any previously reported unresolved claims.
8. After inquiry with each person as appropriate, are you, or any of your partners, officers, Yes No
directors, 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.
9. After inquiry with each person as appropriate, have you, or any of your partners, officers, directors, Yes No
or employees been the subject of any complaint or subject to any disciplinary action by any state
licensing agency or other regulatory body during the last 12 months?
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.
INSURANCE AND LOSS HISTORY
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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.
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:
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