Phone: (972) 235-3030
Toll-Free: (866) 900-RISK

Your Specialist

Lauren Morris
EXT 120
lauren@riskpro.us



About 15 mins to complete application.
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PLEASE NOTE, in order for us to provide an accurate quote, ALL QUESTIONS must be answered. If you are unsure, please answer to the best of your knowledge.

Legal Name of Firm
Contact Name & Title
Sole Proprietorship
Partnership/LLP
Corporation/LLC
Independent Contractor
Other:

Street
City
State
Zip

Telephone
E-Mail

  • Is Principal Owner a Member of the National Association of Realtors?
    Yes
    No

    If yes, NRDS#

  • Requested Effective Date:

  • Month/Year Business Established:

  • List of All States in Which Applicant Conducts Business:

  • Is Applicant independently owned and operated?
    Yes
    No

    If no, please describe:

  • HOW DID YOU HEAR ABOUT US?
    Google Adwords
    Search Engine
    Referred
    Direct Mail
    Other:

    Is the firm or anyone in the firm involved with and /or providing any of the following services or activities: Environmentally Impacted Sites, Mineral/Oil/Gas Rights, Appraisal Management, Services for Hotels/Motels/Mobile Homes/RV Park, Mortgage Banking, Formation or management of Group Investments/Syndications/Trusts/ and/or Partnerships, Title/Abstract/Escrow, Property Preservation, Timeshare Sales, 1031 Exchange, Business Valuations, or Management of REO Property.

    These specialized areas will require a different application. Please describe the services you provide and what percentage of your firms revenue is derived from these services. Then submit this application and we will email you the correct full application you will need to complete.

    All information provided is confidential and will be used soley to obtain an indication for coverage. Coverage cannot be bound from this information.
    Can you answer "no" to all of the following questions?


    1. Does the Applicant operate in California?
    2. Has Principal Broker been licensed as a Real Estate Broker for LESS than three years?
    3. Is the Applicant owned by, controlled by or affiliated with any other entity or does the Applicant own or control any other firm or business?
    4. Has the Applicant, any subsidiary, parent, other related organization or any of the Applicant’s professional staff engaged in any professional practice other than the residential listing and sales during the last 5 years or is expected to engage during the next year?
    5. For the past twelve (12) months, is the total gross income from real estate activities less than $250,000. This should include all income, fees and commissions before the split with brokers or salespeople or deductions or expenses.
    6. Has any one client represented more than 25% of the Applicant’s income or has the Applicant been an exclusive listing agent for any builder or developer?
    7. During the past five (5) years, has any professional liability claim or suit ever been made against the Applicant, any predecessor firm or any of the Applicant’s current or former professional staff?
    8. Does any of the Applicant’s professional staff know of any incident, negligent act, error or omission or other circumstance that could result in a claim or suit against the Applicant or any predecessor firm or any of the Applicant’s current or former professional staff?
    1. Date Applicant established:
    2. Indicate the number licensed agents associated with the Applicant:
    3. For the past twelve (12) months, indicate total gross income from real estate activities. Include all income, fees and commissions before the split with brokers or salespeople or deductions or expenses: $
    4. Please provide information for current E&O policy (if applicable):
      Retroactive/Prior Acts Date
      Carrier
      Limits
      Deductible
      Current Effective Date
    5. Limits of Liability Requested:
      $100,000/$100,000
      $250,000/$250,000
      $250,000/$500,000
      $500,000/$500,000
      $500,000/$1,000,000
      $1,000,000/$1,000,000
      Other:
    6. Deductible Requested:
      $2,500
      $5,000
      $7,500
      Other

    7. All information provided is confidential and will be used soley to obtain an indication for coverage. Coverage cannot be bound from this information.

    1. Has this firm undergone a change in ownership, name or operations including acquisition or mergers?
      Yes
      No

      [Note: Coverage is not provided for predecessor firms or prior principals unless approved by the insurance company. ]
      If yes, please explain:

    2. Complete the following for each principal, partner, director or officer.
      1) Name:

      Title/Position:

      % Ownership:

      Current License Status:
      Active
      Inactive

      Month and Year First Licensed as:
      Agent:
      Broker:
      Other:

      Professional Designations:


      License Ever
      Revoked or Suspended:
      Yes
      No


      2) Name:

      Title/Position:

      % Ownership:

      Current License Status:
      Active
      Inactive

      Month and Year First Licensed as:
      Agent:
      Broker:
      Other:

      Professional Designations:


      License Ever
      Revoked or Suspended:
      Yes
      No


      3) Name:

      Title/Position:

      % Ownership:

      Current License Status:
      Active
      Inactive

      Month and Year First Licensed as:
      Agent:
      Broker:
      Other:

      Professional Designations:


      License Ever
      Revoked or Suspended:
      Yes
      No


    3. Please list all additional principal, partner, director or officer.
    4. Complete the following for the firm’s staff (include individual only once):
      Real Estate Professionals:
      Full Time:
      Part Time:
      Inactive:

      Other (please describe):
      Full Time:
      Part Time:
      Inactive:

      Describe others:
    5. Does the firm:
      a) Have any one client, which represents more than 25% of the firm’s income and/or listings?
      Yes
      No
      If yes, please explain:

      b) Or any individual or entity proposed for coverage have an exclusive listing agreement with any builder/developer?
      Yes
      No

      If yes, number of units sold in the past 12 months:

      Income for the past 12 Months: $
    6. Property values of your 5 largest transactions in last 3 years:
      $
      $
      $
      $
      $
    7. Are you involved in the folowing Real Estate Activities?
      NOTE: Show all income, fees and commissions BEFORE split with brokers or salespeople or deduction of expenses. (Do not Include Property Values)

      Residential Real Estate Sales (1-4 units):
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Farm, Agriculture and/or Forestry:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Land and Lot Sales:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Commercial, Industrial, Income Property Sales:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Business Opportunities Brokerage:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Real Estate Leasing Fees:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Real Estate Consulting/Counseling:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Residential Real Estate Appraisal:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Commercial Real Estate Appraisal:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      *Residential Property Management Fees (1-4 Units):
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      *Commercial or Habitational (5+ units) Property:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Management Fees:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Auctioneering (Real Property Only):
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      *Management of associations (i.e., condominium, HOA, etc):
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Mortgage Brokerage/Financial Arrangements:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Referrals:
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Broker Price Opinions (BPOs):
      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $
      Other
      (Please describe in detail):

      Past Fiscal Year:
      # Transactions
      Income $

      Next 12 Months (estimates):
      # Transactions
      Income $

      *A contract may be if reporting income
    8. Total Gross Income for past 3 years:
      1st Year Prior: $
      2nd Year Prior: $
      3rd Year Prior: $
    9. Does the firm or anyone in the firm
      construct
      develop or
      own properties they
      sell
      appraise or
      lease
      N/A
      Please provide description of services and provide commission or fee income from the activities:
      $
    10. Does the firm or any principal engage in any professional or real estate related enterprises or practices? (other than services listed in question 6)
      Yes
      No
      If yes, please explain:
    11. Please indicate the average sale price of residential properties sold by this firm in the past 12 months: $
    12. What % of residential properties sold in the past 12 months:
      Included a home protection or warranty program? %
      Included a signed property disclosure form? %
    13. Do all of the applicant’s brokers and salespersons disclose to their clients, in writing, the legal nature of their relationship? (i.e. whether the salesperson is representing the buyer/seller or both?)
      Yes
      No
    14. During the last 12 months:
      on what % of transactions did the firm represent both the buyer and seller? %
      on what % of transaction did any one agent represent both the buyer and the seller? %
    15. What % of residential properties sold in the past 12 months were:
      Foreclosure Transactions? %
      Short Sale Transactions? %
    16. If involved in Real Estate Appraisal and/or Real Estate Consulting/Counseling, please provide a list of key personnel and qualifications, as well as brochures describing services provided and promotional material (if available), or the firm’s website address
    17. Types of appraisals and gross income from each type.
    18. Please describe the nature of consulting/counseling services provided:
    19. Does the firm:
      a) Have in-house office policy/procedures manual in place?
      Yes
      No

      b) Have a mandatory document retention policy for all transaction files?
      Yes
      No

      c) Use Transaction management software or a transaction coordinator for all transactions?
      Yes
      No

      d) Use local board, state association or other association approved contracts/forms? (If no, email a copy of your forms to lauren@riskpro.us.)
      Yes
      No

      e) Use an in-house counsel, counsel on retainer and/or risk manager?
      Yes
      No

      f) Document each file with your verbal/written communication, recommendations and your client’s instructions?
      Yes
      No

      g) Have written procedures in place to notify management of problem transactions?
      Yes
      No
    20. In the past 12 months, did at least 75% of professional staff, including independent contractors, take:
      a) An approved NAR, State, or local level formal continuing education course designed to reduce real estate professional liability?
      Yes
      No

      b) An in-house seminar conducted by an attorney or risk management consultant?
      Yes
      No

      c) A franchisor risk management seminar?
      Yes
      No
    21. Please indicate desired coverage:
      a) Limits of Liability (each claim / annual aggregate) $
      b) Deductible per claim $
      c) First Dollar Defense coverage option (additional premium):
      Yes
      No
    22. Do you currently have a professional liability insurance policy in force?
      Yes
      No

      If yes, what is your retroactive date? (MM/DD/YYYY)
    23. If answering yes, please forward a copy of your current declarations page and prior acts endorsement. If current coverage is in place, please complete the following for your firm with respect to Real Estate Professionals Errors and Omissions Liability Insurance for the prior policy period:
      Policy Effective Date? (MM/DD/YYYY)
      Insurance Company:
      Limits of Liability: $
      Deductible: $
      Annual Premium: $
    24. During the past 6 years, has any Insurance Company declined, canceled or refused to renew the applicant, any predecessor firm or anyone indicated in Question 2 or 3?
      Yes
      No

      If yes, please explain
    25. Answer questions 23-25 only after inquiry of each member of your firm. If yes, please provide 6 years of carrier loss runs.
    26. Have any claims (including violations of fair housing laws) been made against your firm, predecessor firm or anyone indicated in Question 2 or 3?
      Yes
      No
    27. Are you aware of any act, error, omission or other circumstances, which might reasonably be expected to be the basis of claim or suit?
      Yes
      No
    28. Have all matters in Questions 23 and 24 above been reported to the applicant’s former or current insurers?
      Yes
      No
      N/A
    29. Note: Incidents or potential claims which might reasonably be expected to result in a claim being made should be reported to your present insurance company.

      I/We hereby declare that the above statements and declarations are true and that I/We have not suppressed or misstated any material facts. I/We agree that any misrepresentation or misstatement of material facts may void coverage under this insurance. I/We agree that this application shall be the basis of the contract with the company and that coverage, if written, will be provided on a claims made basis. It is understood and agreed that completion of this application does not bind the company to provide coverage or the applicant to purchase the insurance.
      Check here to agree to the above statement:
      Name:
      Title:
      Date:

      All information provided is confidential and will be used soley to obtain an indication for coverage. Coverage cannot be bound from this information sheet.



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