Real Estate E&O APP

Real Estate Errors & Omissions - All States

Applicant may qualify for an INSTANT QUOTE by completing Section I below. Section II answers (and Section III if package is desired) will be required prior to binding and are subject to underwriting approval.

I. Instant Quote Information

Instant quote is not available for accounts with losses in the past 5 years. If there is a loss history, please complete Section I. and submit details in a claim supplement.

Applicant's Name:*

Prefix First Last Suffix

Location Address:*

Street Address Address Line 2 City State ZIP Code

Same as Mailing?*

Yes
No

Other Address:

Street Address Address Line 2 City State ZIP Code

Web Address:*

Email Address of Primary Contact:*

Total number of real estate agents/brokers/property managers/independent contractors:*

Full Time

Part Time

Residential Sales $:*

Commercial Sales $:*

Raw Land Sales $:*

Residential property management/leasing $:*

Commercial property management/leasing $:*

Residential vacant land sales $:*

Commercial vacant land sales $:*

Appraisals/Broker price opinions $:*

Consulting $:*

Other (Please Specify) $:*

Is the applicant affiliated with a franchise?*

Yes
No

II. Underwriting Information

1. Has the applicant’s principal or managing partner been either a licensed agent for a minimum of five years or a licensed broker for a minimum of two years?*

Yes
No

Date Business Established:*

2. Please advise if more than 10% of the income is derived from any of the following:

a) construction/development activities:*

Yes
No

b) sale, management or leasing of properties constructed/developed by the applicant or any related entity:*

Yes
No

c) from the sale of agent owned properties:*

Yes
No

d) sale of real estate at any one location or development (subdivision) or one builder/ developer:*

Yes
No

e) from real estate auctioneering, business brokering and/or referral services:*

Yes
No

3. Is more than 25% of income derived from foreclosure sales/REO/short sales?*

Yes
No

4. Do you derive income from any activitiy/profession other than from the scope of a real estate organization?*

Yes
No

If “Yes,” please advise details:

5. Do more than 50% of the applicant’s transactions involve services as a dual agent?*

Yes
No

6. Does the average value of properties sold exceed $600,000?*

Yes
No

7. Expiring insurance information:

Carrier:*

Limits:*

Retention:*

Premium:*

Retroactive Date:*

(Attach a statement of details for all “yes” answers to the following questions)

8. Has any person proposed for insurance had his/her license revoked, suspended, been fined, or been subject to any disciplinary action or investigation by any real estate association, state licensing board or other regulatory body?*

Yes
No

Statement of Details:

9. Has the applicant been the subject of any reportings/complaints to a Better Business Bureau, Federal Trade Commission or any other consumer protection group?*

Yes
No

Statement of Details:

10. Has any policy for Real Estate Agents E&O Insurance ever been cancelled or non-renewed?*

Yes
No

Statement of Details:

(Do not answer if applicant is located in Missouri)

11. Within the last five years, has any claim been made or suit brought against the applicant, its predecessor(s) in business, or any of its present or former owners, partners, officers, directors, employees or independent contractors? If “Yes,” complete USLI Claim Supplement for each claim.

Yes
No

12. Is any owner, partner, officer, director, employee, or independent contractor aware of any circumstance, allegation, contention or incident which may result in a claim being made against the applicant, its predecessor(s) in business, or any of its present or former partners, owners, officers, directors, employees or independent contractors?*

Yes
No

If “Yes,” complete USLI Claim Supplement for each claim.

III. BUSINESSOWNERS PACKAGE INSURANCE

1. Has the applicant had any general liability or property claims paid, reserved, or pending in the last five years?*

Yes
No

If “Yes,” provide details:

2. Does the applicant want any additional insured(s) included on general liability?*

Yes
No

If “Yes,” attach details including name, relationship to applicant and address.

Name:

First Last

Relationship to Applicant:

Address:

Street Address Address Line 2 City State ZIP Code

3. Personal property limit including computer hardware (at 80% coinsurance/replacement cost):3. Personal property limit including computer hardware (at 80% coinsurance/replacement cost):*

4. Building characteristics:

a) Are functioning burglar alarms present?*

Yes
No

b) Is all electrical wiring connected to functional and operational circuit breakers?*

Yes
No

c) Are there functioning smoke and heat detectors in all units and/or occupancies?*

Yes
No

d) Is aluminum wiring present in the building?*

Yes
No

5. Property protection class (1-10):*

6. Building construction (please check one):*

Frame - Bldg. is made from a wood frame (2x4’s/veneers)
Joisted masonry - Outside walls are constructed with bricks/cinder blocks. Roof is made of wood.
Masonry non-combustible - Same as joisted masonry except roof is steel.
Fire resistive - Structural steel framing, reinforced concrete outside/load bearing walls.

IV. ADDITIONAL APPLICANT INFORMATION

Applicant’s mailing address:*

Street Address Address Line 2 City State ZIP Code

FRAUD STATEMENTS

Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application for the policy or otherwise.

Colorado Fraud Statement: 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.

District of Columbia Fraud Statement: 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 Statement: 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.

Florida Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.

Kansas Fraud Statement: 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 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 may be guilty of a crime and may be subject to fines and confinement in prison.

Kentucky Fraud Statement: 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 Statement: 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 a denial of insurance benefits.

Maine Disclosure: A binder may not be withdrawn but a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.

Maryland: 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.

Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium. New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents, occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This policy shall cover only those claims made against an insured while the policy remains in effect for incidents reported during the Policy Period or any subsequent renewal of this Policy or any extended reporting period and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period coverage. The policy includes an automatic 60 day extended claims reporting period following the termination of this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium increases independent overall rate increases until the claims-made relationship has matured.

North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and 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.

Ohio Fraud Statement: 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. I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the company the right to rescind it. By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications are incorporated into, and shall form part of, this policy.

Oklahoma Fraud Statement: 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 Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania Fraud Statement: 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 and Virginia Fraud Statement: 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.

Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy.

Vermont Fraud Statement: 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 may be subject to fines and confinement in prison.

Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an option to purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the extended reporting period shall be part of the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an extended reporting period, please contact your insurance company or your insurance agent. Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Utah Fraud Statement: 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.

Washington Fraud Statement: 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 a denial of insurance benefits.

Fraud Statement (All Other States): 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.

SPECIAL NOTICES - Real Estate Product

Missouri & Rhode Island Disclosure Notice: I understand and acknowledge that as respects Discrimination and Lock Box coverage that Claims Expenses are a part of the Limit of Liability. This means that Claims Expenses will reduce my limits of insurance and may exhaust them completely and should that occur; I shall be liable for any further Claims Expenses. Claims Expenses are as defined in Section VII. I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations.

Producer Name:*

Retail Agency Name:*

LIcense #:*

Main Agency Phone Number:*

Agency Mailing Address:*

Street Address Address Line 2 City State ZIP Code

The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium charged, based on the Insurer’s underwriting guides [not applicable in Maine]. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued and it will be attached and become a part of the Policy.

New York Fraud Statement: 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.

Applicant's Signature:*

Title:*

Date*

Real Estate E&O APP

Real Estate Errors & Omissions APP

Real Estate Errors & Omissions - All States

I. Instant Quote Information

II. Underwriting Information

III. BUSINESSOWNERS PACKAGE INSURANCE

IV. ADDITIONAL APPLICANT INFORMATION