Real Estate Professional Liability Insurance Application

Real Estate Claims-Made Professional Liability Insurance Application

Print and fax completed application to 800-344-5422 or email to johnt@landy.com (submit in PDF format).
Each question requires an answer. Answer each question completely. If the question does not apply, type n/a.
Application must by signed and dated by a principal of the form.
If additional space is required to respond to the questions, please provide your response on your letterhead referencing question, and sign and date.
Incomplete or unsigned applications will be returned for completion. For questions please contact the Herbert H. Landy Insurance Agency at 800-336-5422.

Name of Applicant

Company name if applicable

Contact

Address

Street Address

Address Line 2

City

State

Zip Code

Telephone

Fax

Email Address

Date Firm Was Established (mm/dd/yyyy)

Desired Effective Date (mm/dd/yyyy)

3a.

Is the Applicant a

Corporation Independent Contractor Sole Proprietor Partnership

3b.

Does the firm plan on acquiring or merging with another firm or consolidating its operations during the current policy term? Yes No

If Yes, please provide details and an estimated percentage of growth or consolidation:

Coverage Selection

Check the limit of liability selected	Check the deductible option desired
$100,000/$100,000	Zero
$100,000/$300,000	$1,000.00
$250,000/$250,000	$2,500.00
$500,000/$500,000	$5,000.00
$500,000/$1,000,000	$10,000
$1,000,000/$1,000,000	Other $
$1,000,000/$2,000,000

Optional Coverages: Check if desired

$250,0000 Discrimination Coverage,
Defense only

$250,0000 Discrimination Coverage, Defense and Indemnity

California Enhancement Package Mortgage Brokering Coverage Insurance Agent E&O Coverage

Provide your gross revenues from the last fiscal year. If newly established, please provide an estimate of gross revenues for the current annual period. Do not include revenues from properties in which you have any ownership. (Gross revenues are defined as all fees and commissions before expenses, including fees, commissions and bonuses payable to employees and independent contractors.)

		Gross Revenues for Last Fiscal Year	# of Transaction Sides (closed Real Estate Sales for last Fiscal Year)	Projected Revenues for Current Fiscal Year
a.	Residential Real Estate
b.	Residential Farm Land
c.	Residential Appraisals
d.	Commercial Appraisals
e.	Title Agent Activities
f.	Auctioneering (Real Property)
g.	Raw Land Zoned Residential
h.	Commercial Real Estate
i.	Industrial Real Estate
j.	Non-residential Farm Land
k.	Property Management
l.	Raw Land Zoned (Non-Residential)
m.	Real Estate Consultations (provide details)
n.	Residential Leasing (no mgmt)
o.	Commercial Leasing (no mgmt)
p.	Mortgage Brokering (only if coverage is desired)
q.	Other (specify)
Details of Real Estate Consulting (m) and Other (r) from above:

7a.

Is the applicant owned by, associated with, or controlled by any business, investment group, or syndication? Yes No

If Yes, please provide the name of the entity(s) and the nature of the relationship:

7b.

Is the applicant involved in property development or construction (including renovations)?
Yes No

If Yes, please provide the extent of the firm's involvement and the percentage of revenues generated from such activities:

7c.

What percentage of sales are from new construction? %

Do you have any exclusive listing agreements with any Builder(s)/Developer(s)? Yes No
If yes, please complete this supplement: Supplemental Application (Supplement form is not fillable online. Please print and complete supplement, then fax to 800-344-5422)

7d.

For Appraisers Only:

What percentage of Prior Year Assignments
were for pre-construction or proposed construction properties? %

8a.

Indicate the total number of Professionals*

8b.

Indicate the number of part-time Professionals**

*Professionals are defined as: Owners, Partners, Officers, Real Estate Brokers/Agents/Salespersons, Appraisers, Property Managers, Consultants or Auctioneers including Independent Contractors for whom coverage is desired.

**Part-Time Professionals are defined as: earning $20,000.00 or less in annual income.

8c.

Complete the following for each professional listed above:

	Name and Title	Professional Designations	Broker?	Date First Licensed (mm/dd/yyyy)
1.			Yes No
2.			Yes No
3.			Yes No
4.			Yes No
5.			Yes No

9a.

Please indicate the number of Owners, Officers, Partners and Professional Employees who partcipated in a formal real estate continuing education program during the last 12 months

9b.

Do you provide in-house training of your personnel? Yes No

9c.

Do you use standardized contracts and forms? Yes No

If yes, what is the percentage of use? 100% 75% 50% Less than 50%

9d.

Does the firm offer a Home Warranty Program at all closings? Yes No

If yes, what program is offered?

9e.

What percentage of transactions involve acting
as a dual agent, intermediary or transactional broker? %

9f.

If your state recognizes dual agency, what is the percentage
of transactions by a single agent representing both the buyer and seller in a single transaction? %

9g.

Are you a member of the California Association of Realtors? Yes No

If yes, have you attended a CAR sponsored risk management program within the last year? Yes No

10.

Do you transact business in multiple states? Yes No

If yes, please list the state(s) involved and the percentage (%) of total gross revenues from each state:

	State	Percentage (%)
a.		%
b.		%
c.		%
d.		%
e.		%

11.

Is the applicant, or anyone to whom this insurance will apply, aware of any
(including optional coverage indicated in quesiton 5):

a. Professional Liability Claim made against them in the past 5 years? Yes No

b. Act or omissions which might reasonably be expected to be the basis of a claim or suit against them arising out of the performance of professional services for others? Yes No

c. Changes in any claims previously reported on past applications? Yes No

IF YOU ANSWERED YES TO QUESTION 11a, b, or c, CLICK HERE TO COMPLETE THIS SUPPLEMENTAL CLAIM FORM FOR EACH CLAIM.(Supplement form is not fillable online. Please print and complete supplement, then fax to 800-344-5422) IMPORTANT NOTICE: Failure to report to your current insurance agency any claim made against you during your current policy term, or facts, circumstances or events which may give rise to a claim against you BEFORE the expiration of your current policy term may jeopardize your coverage.

12.

Has the firm, or anyone to whom this insurance will apply, had their license revoked, been investigated, or been subject to disciplinary action by any Real Estate Association, licensing board or other regulatory body within the last five years? Yes No
If yes, please forward a copy of initial complaint, your response to complaint and final ruling.

13.

NOTICE TO MISSOURI RESIDENTS: THIS QUESTION DOES NOT APPLY
During the past 5 years has any insurance carrier declined, canceled or refused renewal of similar insurance on behalf of this applicant or anyone to whom this insurance will apply? (Other than due to loss of market)
Yes No

If yes, please provide details to include the date, carrier and reason:

14.

List Previous Professional Liability Coverage policies this individual, firm or predecessors of firm have held within the last 5 years. If no insurance was in effect for a given year, state "none" where applicable below.

	Company		Policy Period (mm/dd/yyyy)
a.			to
	Limit of Liability	Deductible	Premium

	Company		Policy Period (mm/dd/yyyy)
b.			to
	Limit of Liability	Deductible	Premium

	Company		Policy Period (mm/dd/yyyy)
c.			to
	Limit of Liability	Deductible	Premium

	Company		Policy Period (mm/dd/yyyy)
d.			to
	Limit of Liability	Deductible	Premium

e.	Company		Policy Period (mm/dd/yyyy)
			to
	Limit of Liability	Deductible	Premium

15.

Has the applicant ever purchased an extended reporting period endorsement? Yes No

If yes, please indicate the effective date of the endorsement (mm/dd/yyyy):
Length of reporting period

NOTICE (for all states except Florida): By applying for this insurance, the applicant also is applying for membership in Realtors Insurance Purchasing Group Association, a purchasing group formed and operating pursuant to the Federal Liability Risk Retention Act of 1986 (15 USC 3901 et seq.). This purchasing group was formed for the sole purpose of providing professional errors and omissions liability insurance to real estate professionals. The sole purpose of becoming a member is to purchase professional liability insurance.

Fraud Warning (not applicable in Nebraska, Vermont or Virginia): Any person who knowingly, and with the 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 purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT'S ACCEPTANCE OF COMPANY'S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. IT IS AGREED
THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED,
AND IT WILL ATTACH TO THE POLICY.

General Star National Insurance Company is an "admitted" or "licensed" insurer in all state except Connecticut (where General Star Indemnity Company is "admitted" or "licensed"), subject to the financial solvency regulation and enforcement, which applies to licensed companies. This insurance company participates in state insurance guarantee funds.

For California Residents: General Star Indemnity Company is a "non-admitted" or "surplus lines" insurer in California and is not subject to the financial solvency regulation and enforcement, which applies to licensed companies. The insurance company does not partcipate in any state insurance guarantee fund; therefore, these funds will not pay your claims or protect your assets if the insurance company becomes insolvent and is unable to make payments as promised. Your agent or broker can verify with the State Insurance Commissioner that General Star Indemnity Company is an approved surplus lines insurer in the state. California Surplus lines license #OB11941, Herbert H. Landy Insurance Agency, Inc., Needham, MA, 02494.

I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my Professional Liability application.

The Electronic Signature Process (E-signature) provides you with a faster and more convenient way to process your application. Filling out this text box is the equivalent of signing your name.

E-Signature (please type your name) Date

Print and Fax Completed Application to 800-344-5422 or Email Completed Application to johnt@landy.com
(submit in PDF Format)

PRINT APPLICATION

The Herbert H. Landy Insurance Agency, Inc.
75 Second Avenue, Suite 410
Needham, Massachusetts 02494
Phone: (800) 336-5422 • Fax: (800) 344-5422

GSM-06-RE-650 April 2008