Form Rea - Real Estate Errors And Omissions Liability Application Form (Page 2 of 2) in pdf

8. Percentage of Home Warranties sold on all transactions in the past 12 months: _________________________________________

9. What percentage of applicant’s commission income is derived from the sale of owned property?

__________%

10. What is the average value of units sold? _________________________________

11. Is more than 10% of applicant's commission income derived from the sale of real estate at any one location or development?

Yes

If Yes, please advise details on separate sheet.

12. Does applicant’s firm have an in-house Policy Procedures Manual? ........................................................................... Yes

13. Has the applicant or any past or present staff member had their license revoked, or been subject to disciplinary action or

investigation by any Real Estate Association, State Licensing Board or other regulatory body? ................................. Yes

If Yes, please provide details, date of occurrence and a copy of all findings by this regulatory agency. ______________________

________________________________________________________________________________________________________

14. Current Insurance

E&O Insurance Co.

Policy Period

Limit of Liability

Premium

Deductible

a. __________________

______________ __________________

__________

____________

b. How many years has an E&O policy been in place without any lapses in coverage?___________________________________

c. Has the applicant ever purchased an extended reporting period endorsement? ......................................................Yes

If Yes, please explain on a separate sheet.

d. During the past five years has any insurance carrier declined, cancelled 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.)

Yes

If yes, please explain: ____________________________________________________________________________________

______________________________________________________________________________________________________

15. Does applicant’s firm maintain General Liability Insurance? ....................................................................................Yes

16. Is the applicant or anyone for whom this insurance will apply aware of any:

a. Professional Liability claim made against them in the past 5 years? ......................................................................Yes

b. Fact, circumstance, situation, act or omission which might reasonably be expected to be the basis of a claim or suit

against them? ........................................................................................................................................................... Yes

If "Yes," to any of 16 (a) or (b) please complete the Supplemental Claim Form.

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.

The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. The

undersigned further declares that any occurrence or event taking place prior to the effective date to the insurance applied

for which may render inaccurate, untrue or incomplete any statement made will immediately be reported in writing to the

Insurer and the Insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the

insurance. 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 stop the Insurer from

relying on any statement in this Application. The signing of this application does not bind the undersigned to purchase the

insurance, nor does the review of this Application bind the insurance company to issue a policy. It is understood the

Insurer is relying on 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.

Signature of the applicant: _________________________________________________________________________

Must be signed by a Principal, Partner or Officer of the Firm

Date: ___________________________

IF THE PRIMARY ADDRESS OF THE LOCATION LISTED IN ITEM #1 IS IN THE STATE OF NEW YORK, IOWAAND

FLORIDA, THE STATE OF NEW YORK, IOWAAND FLORIDA REQUIRE THAT WE HAVE THE NAMES AND ADDRESSES

OF YOUR (INSURED'S) AUTHORIZED AGENT OR BROKER.

NAME OF AUTHORIZED AGENT OR BROKER:_________________________________________________________________

ADDRESS: _________________________________________________________________________________________________

AGENT OR BROKER LICENSE NUMBER: ______________________________________________________________________

REA (REV 12/19/02)

2 of 2

Form Rea - Real Estate Errors And Omissions Liability Application Form Page 2

Related Articles

Related forms

Related Categories