• EXPRESS APPLICATION

    EXPRESS APPLICATION

    Real Estate Professional Errors and Omissions Insurance

  • CALIFORNIA RESIDENTS, USE THIS APPLICATION: Express Application for California

    FLORIDA RESIDENTS, USE THIS APPLICATION: Express Application For Florida

  • IMPORTANT!

    To be eligible for this Express Application (and the premium options below), the responses to True/False Eligibilty Statements 1-9 must all be 'True.' If you are not eligible for this program, please use the Standard Application.

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  • TRUE/FALSE ELIGIBILITY STATEMENTS (1-9)

    To be eligible for this Express Application (and the premium options below), the responses to True/False Eligibilty Statements 1-9 must all be 'True.' If you are not eligible for this program, please use the Standard Application.

  • IMPORTANT! 

    Do not continue with this application. DO NOT PAY on the next screen!

    If you answered "False" to any of the Eligibility Statements 1 through 9 on the previous page, then you are NOT eligible to apply with this application and must apply with the Standard Application.

  • SELECT YOUR DESIRED ANNUAL PREMIUM OPTION AND REMIT WITH YOUR APPLICATION

    ALL STATES EXCEPT CALIFORNIA

  • Florida, Kentucky, New Jersey and West Virginia Applicants: Please see notes below regarding State taxes or surcharges required.

  • Claim Expenses are Outside the Limits of Liability

    Deductible Loss & Expense

  • CALCULATE TOTAL DUE

  • Kentucky Residents:

    The premiums above do not include the State, City or County Taxes assessed in Kentucky. Contact your agent to obtain the amount of the tax prior to submitting this application.

  • West Virginia Residents:

    The State of West Virginia assesses a tax of 0.55% on insurance. Multiply premium you selected above by 1.0055 and round to the nearest dollar. This is the total premium and tax due.

  • Florida Residents:

    Companies writing property and casualty insurance business in the State of Florida are required to collect a Florida Hurricane Catastrophe surcharge. Multiply the premium you selected above by the appropriate factor and round to the nearest dollar. This is the total premium and surcharge due.

  • New Jersey Insurance Guaranty Association Fund:

    Companies writing property and casualty insurance business in New Jersey are required to participate in the New Jersey Insurance Guaranty Association. If a company becomes insolvent, the Guaranty Association settles unpaid claims and assesses each insurance company for its fair share. The current assessment will be displayed on your premium notice. Multiply the premium you selected above by the current assessment and round to the nearest dollar. This is the total premium and assessment due.

  • FRAUD WARNING: 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 subjects such person to criminal and civil penalties. ARKANSAS, LOUISIANA AND WEST VIRGINIA FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO FRAUD WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insuranc e benefits, and/or civil damages. In Colorado, any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. D.C. FRAUD WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA FRAUD WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. KANSAS FRAUD WARNING: KANSAS FRAUD WARNING: A "fraudulent insurance act" means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. KENTUCKY FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MAINE FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

    MARYLAND FRAUD WARNING: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MINNESOTA FRAUD WARNING: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW JERSEY FRAUD WARNING: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK FRAUD WARNING: 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. OHIO FRAUD WARNING: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material to the content of the contract commits a fraudulent insurance act, which may be violating state law and may be subject to prosecution for insurance fraud. PENNSYLVANIA FRAUD WARNING: 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 subjects such person to criminal and civil penalties. TENNESSEE FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. VIRGINIA AND WASHINGTON FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. VERMONT FRAUD WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

  • DISCLAIMER

    COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANT AND FIRM ACCEPTS NOTICE THAT ANY POLICY ISSUED WILL APPLY ON A “CLAIMS-MADE” BASIS. THE APPLICANT AND FIRM ACCEPTS NOTICE THAT THEY ARE REQUIRED TO PROVIDE WRITTEN NOTIFICATION TO THE COMPANY OF ANY CHANGES TO THIS APPLICATION THAT MAY HAPPEN BETWEEN THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE. THE APPLICATION MUST BE SIGNED BY AN ACTIVE OWNER, PARTNER, PRINCIPAL, OFFICER, OR MEMBER OF THE APPLICANT.

  • The undersigned is authorized by, and acting on behalf of, the Applicant and represents that all statements and particulars herein are true, complete and accurate to the best of their knowledge and that there has been no suppression or misstatements of fact and agrees that this application shall be the basis of, and becomes part of, the Applicant’s professional liability coverage. 

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  • Your application will not be submitted until you click the green button below.

    REMEMBER YOUR TOTAL!

    USE THIS AMOUNT ON PAYMENT SCREEN (NEXT STEP).

  • ATTENTION! 

    • Payment and completion of this form does NOT bind coverage. Coverage is not bound until the application is reviewed and accepted by underwriting.
    • Please note: ACH/Credit Card fees are charged by the payment processor and fully earned.
    • IF YOU DID NOT ANSWER "TRUE" TO ALL ELIGIBILITY STATEMENTS 1-9, DO NOT PAY ON THE NEXT PAGE!
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