E&O coverage application

Real Estate Agent/Broker Errors & Omissions. This is an application for a claims-made policy — let's start with your firm.

Any additional office locations?

None Yes

Your business background

When you started, and how the applicant is organized.

Date business was established

Date licensed as a Broker

Date licensed as an Agent

Is the applicant a:

Corporation Partnership Sole Proprietorship Independent Contractor

Applying for coverage as a:

Firm Individual

If individual — are you the Broker/Owner?

Yes No

Outside business ventures

Activities beyond the scope of a real estate organization.

Has the applicant or its predecessor firm at any time engaged in any business venture outside the scope of a real estate organization (construction, property development, mortgage banking, mortgage brokering, insurance, etc.)?

No Yes

Please advise details

Has more than 10% of your firm's income been derived from property development or construction activities?

No Yes

Do you understand there is NO coverage under the proposed policy for loss or defense costs involving construction, development, sale or resale of real property developed or constructed by any applicant?

Yes No

Your team

Total for each category — list each person only once, by their primary area of responsibility. Leave blank for zero.

Gross revenue

All fees and commissions for the past twelve months, before expenses — revenue from the sale of property, not the value of properties sold.

Description

Last 12 mo ($)

# Trans.

Next 12 mo ($)

Residential (incl. owned farms)

Commercial (incl. residential over 4 units)

Property mgmt — residential

Property mgmt — commercial

Appraisal fees — residential

Appraisal fees — commercial

Mortgage broker

Other

Residential means properties of up to four units; more than four units is commercial. Appraisal over 35% of revenue or mortgage broker revenue over $250,000 requires a separate addendum — we'll follow up if that applies.

Sales profile & practices

For the past twelve months (or your estimate for the coming year if new in business).

Residential — average value ($)

Residential — maximum value ($)

Commercial — average value ($)

Commercial — maximum value ($)

% of transactions with home warranties sold

% of dual-agent transactions (past 3 yrs)

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

No Yes

Does your firm have an in-house Policy & Procedures Manual?

Yes No

Has the applicant or any past or present staff member had their license revoked, or been subject to disciplinary action by any Real Estate Association, State Licensing Board or other regulatory body?

No Yes

Current insurance

Your existing E&O policy, if you have one. Leave blank if not currently insured.

Retro date

Has the applicant ever purchased an extended reporting period endorsement?

No Yes

During the past five years, has any carrier declined, cancelled or refused renewal of similar insurance for this applicant, a predecessor firm, or anyone this insurance will apply to?

No Yes

Requested coverage

Choose your limits and deductible, confirm claims history, and sign.

Requested limit

Requested deductible

$5,000 $10,000 Other

Prior acts date (if requesting)

Requested effective date

If you're requesting prior acts coverage, you must currently have coverage matching this date — we'll ask for a copy of your current E&O declarations page.

Does your firm maintain General Liability insurance?

Yes No

Is the applicant, or anyone this insurance will apply to, aware of any professional liability claim made against them in the past five years?

No Yes

Aware of any fact, circumstance, situation, act or omission that might reasonably be expected to be the basis of a claim or suit?

No Yes

Since you answered yes, we'll send you the Supplemental Claim Form to complete after you submit.

Declaration

The undersigned declares that to the best of their knowledge and belief the statements set forth herein are true, and that any occurrence prior to the effective date which may render any statement inaccurate will be reported in writing to the Insurer. Signing this application does not bind you to purchase the insurance, nor the insurance company to issue a policy. Must be signed by a principal, partner or officer of the firm.

I agree to the declaration

Date

Application received

Thanks — we've got your E&O application. Our team will review it and follow up by email, usually within one business day. If a supplemental form applies, we'll include it in that email.