STANDARD APPLICATION FOR CALIFORNIA

STANDARD APPLICATION FOR CALIFORNIA

Real Estate Professionals Errors and Omissions Insurance Application
Who is your insurance agent?*
If you don't know, select "Unknown"
Insurance agent's email address (auto-fill)
(auto-fill)

NOTICE: This is an application for a “Claims-made” policy. Coverage for prior acts and claims made after termination of this policy may be restricted. Please read the policy carefully.
1. Name of Applicant (company name or broker's name)*
This should match the name on your real estate license. If a corporation or LLC, enter the company name. If a sole proprietor, partnership, or independent contractor, enter the broker name. Do not enter DBA’s here.
DBA(s)
Contact*
California Association of REALTORS® member:*

YesNo
Principal Street Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Mailing Address

Mailing Address

Street Address Line 2

CityState

Postal / Zip Code
Telephone*
FAX Number
E-Mail Address:*
example@example.com
Website:*
Enter your company's website address

2.a. Date firm was established:*

MonthDayYear
Date
b. Year current owner assumed management:*
c. Number of years owner licensed as an agent*
Number of years licensed as a broker*
Number of years licensed as as an appraiser (if applicable)
Entity Type*

Corporation/LLCIndependent ContractorSole ProprietorPartnership/LLP

Professionals are defined as: Owners, Partners, Officers, Real Estate Brokers/Agents/Salespersons, Appraisers, Property Managers, Consultants or Auctioneers including independent contractors.
4. a. Indicate the total number of active full time professionals: *Full time professionals are defined as earning more than $20,000.00 in annual income.*
Include yourself in this total, if you make more than $20K/year
b. Indicate the number of active part time professionals: *Part time professionals are defined as earning $20,000.00 or less in annual income.*
Include yourself in this total, if you make less than $20K/year
c. Indicate the total number of support staff:*
If none, enter "0"
and inactive professionals:*
If none, enter "0"
5. Does the applicant have a formalized training program for all professionals and staff?*

YesNo
6. Indicate the number of professional employees who participated in an accredited, continuing professional education program during the past 12 months.*
Include yourself in this total if you have participated in continuing education in the past year
7. Do at least 15% of all professionals hold a professional designation?(i.e. GRI, CRS, CRE, ABR, MAI, SRA)*

YesNo

8. Is the applicant owned, associated, or controlled by any business, investment group or syndication?*

YesNo

If Yes to #8, please provide the name of the entity(s) and the nature of the relationship*
If the applicant is owned, associated, or controlled by another entity, provide details here.

9. a. Has any member of your firm engaged in property construction or development (including renovations)?*

YesNo

If any member of the firm has engaged in property construction, development, or renovations, check all that apply and complete 9b:*

1. Directly (you or any member of your firm doing work themselves)2. Through a licensed contractor3. Through a separate business entity owned by any member of your firm or their spouses (If you checked option 3, please complete supplemental application)Other
If you checked #3, you must complete the Construction/Development Ownership section of the Other Services Supplement.
9. b. Provide gross commission income derived from the sale of these properties in the past 12 months, and include this total in“Agent/Broker Owned Property Sales” under question 10 on the next page.

Check here if none in the last 12 months
Gross Commission Income derived from Construction/Development Activities on RESIDENTIAL properties:*
RESIDENTIAL (if none, enter "0")
Gross Commission Income derived from Construction/Development Activities on COMMERCIAL properties:*
COMMERCIAL (if none, enter "0")

10. Provide your gross revenues for the last 12 months and projected next 12 months. If newly established, please provide an estimate of revenues for the current annual period. (Gross revenues are defined as all fees and commissions before expenses, including fees, commissions and bonuses payable to employees and independent contractors.)

Please note: Your revenue should make sense mathematically with your other numbers. (Average home value X average commission percentage X number of transactions = total gross commissions)

RESIDENTIAL | Enter past and projected revenue information in the table:*

	Gross Revenues Last 12 Months	# of Transactions Last 12 Months	Projected Revenues Next 12 Months	# of Transactions Next 12 Months
Sales
Leasing
Agent/Broker Owned Property Sales
Farm Land
Raw Land
Appraisals*

*If Applicant has revenue derived from Residential Appraisals, please complete the Other Services Supplemental Application.

Does the Applicant have any past or projected Commercial transactions? (ie: Sales, Leasing, Land, Appraisals)*

YesNo

COMMERCIAL | Enter past and projected Gross Commission Income in the table:*

	Gross Revenues Last 12 Months	# of Transactions Last 12 Months	Projected Revenues Next 12 Months	# of Transactions Next 12 Months
Sales
Leasing
Agent/Broker Owned Property Sales
Farm Land
Raw Land
Appraisals*

*If Applicant has revenue derived from Commercial Appraisals, please complete the Other Services Supplemental Application.

Does the Applicant have any past or projected transactions involving Property Management, Business Brokering, Mortgage Brokering, Auctioneering, Short-term Escrow, Consulting, or other services?*

YesNo

OTHER SERVICES | Enter past and projected revenue information in the table:*

	Gross Revenues Last 12 Months	# of Transactions Last 12 Months	Projected Revenues Next 12 Months	# of Transactions Next 12 Months
Property Manager*
Sale of Business Opportunities*
Mortgage Brokering*
Auctioneering (Real Property)*
Short-term Escrow (distributed within 1 year)
Real Estate Consulting (details below)
Other (provide details below)

Details of “Real Estate Consulting” and “Other” from above:
*If Applicant has revenue derived from Property Management, Business Brokering, Mortgage Brokering, or Auctioneering, please complete the Other Services Supplemental Application.

11. Does the applicant have documented procedures which include instructions on how to handle complaints and compliance with Federal, State and Local statutes?*

YesNo

12. Does the applicant use approved board of REALTORS or state association of REALTORS standard contract forms for the listing?*

YesNo

If no to #12, please explain:
If the applicant does not use board approved standard contract forms for listings, please explain here.

13. a. In the past year, what was the average value of properties sold?: *
Your average property value should make sense mathematically with the revenue and number of transactions you reported on #10.
or average value of properties appraised (if applicable)
(if applicable)
13. b. what was the average commission percentage (%) earned on closed real estate sales:*
Please enter your average commission percentage (%), not the dollar amount.

14. Has the applicant ever had a transaction valued at $10,000,000 or more?*

YesNo

If yes to #14, please provide the date(s) of sale, type of property, and sale price(s):*
If the Applicant has ever had a transaction valued at $10M or more, please provide date(s) of sale, property type, and sale price(s).

15. What percentage of residential transactions included a:
% a. Signed property disclosure form?*
% b. Home Warranty program?*
% c. Home inspection or written waiver?*

16. a. What percentage of transactions involve acting as a:
% dual agent*
% intermediary*
% transactional broker*
b. When acting as a dual agent, is dual agency disclosed to all parties in writing?*

YesNo

17. Has any member of your firm been involved in asset or property preservation services including any incidental repair work on bank owned properties within the last 3 year period?*

YesNo

If Yes to #17, were all such repairs contracted by you done by a licensed contractor?*

YesNo
If your firm was involved in asset or property preservation services on bank owned properties, indicate if all such repairs (contracted by you) were done by a licensed contractor.

18. Has any member of your firm been involved in property rehabilitation services on bank owned properties within the last 3 year period?*

YesNo

If Yes to #18, were all such repairs contracted by you done by a licensed contractor?*

YesNo
If your firm was involved in property rehabilitation services on bank owned properties, indicate if all such repairs (contracted by you) were done by a licensed contractor.

19. For any bank owned properties where you represent the buyer, do you advise the buyer in writing to have the property inspected by a licensed and insured home inspector prior to purchase?*

YesNo

If No to #19, please explain:
When representing the buyer of bank owned properties, explain why you do not advise them in writing to have the property inspected by a licensed and insured home inspector prior to the purchase.

20. Has any member of your firm directly acquired the properties or deeds of financially distressed homeowners, including sale–leaseback agreements within the last 3 year period?*

YesNo

If Yes to #20, please provide details:
If you or any member of your firm has purchased properties or deeds directly from financially distressed homeowners within the last 3 years, please provide details of the transaction(s) here.

21. Has the applicant engaged in any eviction services on pre-foreclosed or bank owned properties within the last 3 years?*

YesNo

If Yes to #21, was the preparation, filing and service of the eviction complaint and obtaining the eviction judgment handled by an attorney?*

YesNo
If your firm has engaged in evictions, indicate if the preparation, filing, service, and judgment was handled by an attorney.

22. Has the applicant engaged in any services which involved delivering or negotiating cash-for-keys offers or property rehabilitation?*

YesNo

If Yes to #22, what is the percentage of the gross commission income derived from these services?*
If you have engaged in delivering or negotiating cash-for-keys offers or property rehabilitation, indicate what percentage of your income derived from those services.

23. Is any client responsible for more than 25% of the applicant’s annual income?*

YesNo
(Does 25% or more of your annual income come from a single client?)

If Yes to #23, provide the name, relationship and total revenue from the client:*
If 25% or more of your annual income comes from a single client, please provide more information.

24. Does the firm perform or intend to perform professional services for REITs or property syndications?*

YesNo

If Yes to #24, what is the percentage of the gross commission income derived from these services?*
If the firm is involved in REITs or property syndications, please provide the percentage of income derived from these services.

25. a. During the past 5 years, has the applicant been involved in any merger, acquisition, or consolidation?*

YesNo

If Yes to 25a, provide details including any name changes for the firm:*
If the applicant was involved in a merger, acquisition, or consolidation, provide details here or upload additional information below.
If needed, provide details on a separate sheet and upload here:

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Upload separate sheet, if needed Cancelof

25b. During the past 5 years, has any principal, partner, director, officer, or professional of the applicant performed professional services for any other business which the applicant has any ownership or managerial interest?*

YesNo

If Yes to 25b, provide details:*
If the applicant performed professional services for any other business in which the applicant has ownership or managerial interest, provide details here.

26. Does any applicant transact business in multiple states or outside of the United States?*

YesNo

If Yes to #26, provide details including the percent (%) of total gross revenues from each state or country:*
If the applicant transacts business in multiple states or outside of the U.S., provide a revenue breakdown (% from each state) here.

Is the applicant's expiring E&O policy from RealCare?*

Yes, my expiring policy is from RealCareNo, my expiring policy is NOT from RealCareI am not currently insuredI'm not sure

NEW BUSINESS APPLICANTS ONLY #28-30

Questions 28-30 are only required if the Applicant is new to RealCare
28. 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)? *Notice: This question does not apply to Missouri residents**

YesNo

If Yes to #28, provide details on separate sheet and upload here:

Browse Files
If any insurance carrier has declined, canceled, or non-renewed the Applicant within the past 5 years, please upload details here. *Notice: This does not apply to Missouri residents* Cancelof

29. 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. *

	Carrier	Policy Effective	Policy Expiration	Limits of Liability	Deductible	Premium	Retro Date
Expiring Policy
Previous Policy
Previous Policy
Previous Policy
Previous Policy

30. Has the applicant ever purchased an extended reporting period endorsement?*

YesNo

If Yes to #30, please provide details to include the date, carrier and reason:*
If the applicant ever purchased an extended reporting period endorsement, please provide the date, carrier, and the reason.

31. Coverage Selection:
a. Limit of Liability (Per Claim/Policy Aggregate)
Select your desired limit option
Claims Expenses

Claims Expense Inside the Limit (CEIL)Claims Expense Outside the Limit (CEOL)
b. Deductible
Select your desired deductible option
If you would like to see additional options quoted, please request them here:
List any additional limit and/or deductible options you would like quoted.
c. Desired Policy Effective Date:

MonthDayYear
Date
d. Current Policy Retroactive Date:

MonthDayYear
Date
UPLOAD DECLARATIONS PAGE. If you have a current policy in force, please upload your declarations page here (this is NOT required unless you are a new client with RealCare).

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Upload dec page. **This is NOT required unless you are a new client with RealCare** Cancelof

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 crimina l and civil penalties.

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 and that there has been no suppression or misstatements of fact and agreesthat this application shall be the basis of, and becomes part of, the Applicant’s professional liabilitycoverage.

COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. 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.
Print Name:*
Title:*
Signature*

Clear
Date

MonthDayYear
Date
After signing, you must click the SUBMIT APPLICATION button to submit your application.
Should be Empty:

STANDARD APPLICATION FOR CALIFORNIA

NEW BUSINESS APPLICANTS ONLY #28-30