Application Form Page 2
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4ACTIVITY OTHER THAN PROPERTY MANAGEMENT
12. Other Income. Applicant's Gross Revenue for the past 12 months (all fees and commissions before expenses, including any fees,
commissions, or bonuses payable to employees and independent contractors). Indicate gross revenue derived from the sale of property,
NOT the value of properties sold.
Description
Gross Income
Number of
Projected Income
Last 12 Months
Transactions
Next 12 Months
Residential Sales*
$ _____________
______________
$ _____________
Commercial Sales
$ _____________
______________
$ _____________
Real Estate Appraisal Fees (complete
$ _____________
______________
$ _____________
Appraisers Addendum if over 35%)
Other (Describe __________________________)
$ _____________
______________
$ _____________
TOTALS
$ _____________
______________
$ _____________
* Residential Real Estate means any property containing a single-family dwelling or multiple-family dwellings of up to 4 units. Any
properties with more than 4 units are considered commercial.
CURRENT E&O INSURANCE
13.
Insurance Co.
Policy Period
Limit of Liability
Premium
Retroactive Date
Deductible
(a) ______________________
______________
______________
______________
____________
___________
(b) How many years has an E&O policy been in place without any lapses in coverage? _______________________________________
q Yes
q No
(c) Has the applicant ever purchased an extended reporting period endorsement?
If Yes, please explain on a separate sheet.
(d) During the past 5 years has any insurance carrier declined, canceled or refused renewal of similar insurance on behalf of this
applicant, predecessor firm or anyone for whom this insurance will apply? (Missouri applicants need not answer this question).
q Yes
q No
If Yes, please explain:___________________________________________________________________
__________________________________________________________________________________________________________
14. Has the applicant or any past or present staff member had their license revoked, or been subject to disciplinary action or investigation by
q Yes
q No
any State Licensing Board or other regulatory body?
If Yes, please advise details, date of occurrence and
copy of findings by Regulatory body.
______________________________________________________________________________________________________________
15. Is the applicant or anyone for whom this insurance will apply aware of any:
q Yes
q No
(a) Professional Liability claim made against them in the past 5 years?
(b) Fact, circumstance, situation, act or omission which might reasonably be expected to be the basis of a claim or suit against them?
q Yes
q No
If “Yes”, to any of 15 (a) or (b) please complete the Supplemental Claim Form.
TENANT DISCRIMINATION COVERAGE DETAILS
q Yes
q No
16. Are all properties in full compliance with statutory and regulatory requirements for persons with physical handicap?
q Yes
q No
17. Is more than 25% of the applicant's income from properties financed by Housing and Urban Development (HUD)?
q Yes q No
18. Does the organization currently carry Tenant Discrimination Coverage?
If Yes, please advise Insurance Co., Limit of Liability, expiring premium and date from which this coverage has been
continuously carried:_____________________________________________________________________________________________
19. Is the applicant or anyone for whom this insurance will apply aware of any:
q Yes
q No
(a) Claim alleging Discrimination or violation of any Fair Housing Act made against them in the past 5 years?
(b) Fact, circumstance, act or omission which might reasonably be expected to be the basis of a claim or suit against them?
q Yes
q No
If "Yes", to any of 19 (a) or (b) please complete the Supplemental Claims Form.
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