Form Rea - Real Estate Errors And Omissions Liability Application Form printable pdf download

Real Estate Errors and

Omissions Liability Application

THIS IS AN APPLICATION FOR A CLAIMS-MADE

POLICY. PLEASE READ YOUR POLICY

CAREFULLY.

1. Name of Applicant: ______________________________________________________________________________________

Address:

______________________________________________________________________________________

* List complete addresses of all additional offices on a separate sheet; if none, check here

Contact Name: ________________________ Phone #: ________________________ Fax #: _________________________

2. Date Business was established: ___________________

Date Applicant was licensed as a Broker: __________________

Date Applicant was licensed as an Agent: ___________________

3. Is the applicant a(n): Corporation:

Partnership:

Sole Proprietorship:

Independent Contractor:

4. Is applicant applying for coverage as a(n): Firm: Individual: If Individual, is applicant the Broker/Owner? ......Yes

5. Has Applicant, its Predecessor Firm or any Affiliated Firm at any time in the past or present engaged in any business venture

outside the scope of a Real Estate Organization, including but not limited to, construction, property development, mortgage

banking, mortgage brokering or insurance?

Yes

If Yes, please answer the following questions:

(a.) Please advise details: __________________________________________________________________________________

___________________________________________________________________________________________________

(b.) Has more than 10% of your real estate firm's income been derived from property development or construction activities?

Yes

(c.) Does the applicant understand that there is NO coverage under the proposed policy for Loss or Defense Costs in connection

with claims involving the construction, development, sale or resale of real property developed or constructed by any

applicant?

Yes

6. Total number for each category (list each person only once, identifying his or her primary area of responsibility).

Full Time

Part Time

___________

___________ Real Estate Agents/Brokers/Independent Contractors

(1)

___________

___________ Property Managers

(2)

___________

___________ Appraisers

(3)

___________

___________ Mortgage Brokers

(4)

___________

___________ Realtor Assistants

(5)

___________

___________ Clerical

(6)

___________

___________ Other (Please describe: ______________________________________________)

(7)

___________

___________ TOTAL

(8)

7. 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 Last

Number of

Projected Income Next

12 Months

Transactions

12 Months

ential Sales (Including owned farms)*

Resid

Commercial Sales (Including residential

properties over 4 units)

Residential Property Management*

Commercial Property Management

Residential Real Estate Appraisal Fees*

Commercial Real Estate Appraisal Fees

(Complete addendum if over 35%)

Mortgage Brokering

Other (Describe __________________)

TOTAL

* 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.

REA (REV 12/19/02)

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Form Rea - Real Estate Errors And Omissions Liability Application Form

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