STANDARD APPLICATION

STANDARD APPLICATION

Real Estate Professionals Errors and Omissions Insurance
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*
Principal Street Address *

Principal Street Address

Street Address Line 2

CityState / Province

Zip
Mailing Address

Mailing Address

Street Address Line 2

CityState / Province

Zip
Telephone*
I give RealCare permission to text me if they are unsuccessful reaching me by phone.
Fax Number
E-Mail Address:*
example@example.com
Website*
Enter your company's website address
Make sure to save your application in case you need to continue it later:

2.a. Date firm was established:*

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

Corporation/LLCIndependent ContractorSole ProprietorPartnership/LLP
Professionals are defined as: Owners, Partners, Officers, Real Estate Brokers/Agents/Salespersons, Appraisers, PropertyManagers, 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:*
and inactive professionals:
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.*
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 Yes to 9a, check all that apply:*

1. Directly (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 #3, please complete supplemental application, link below)*Other
*If you checked box #3, you must complete the Construction/Development section of the Other Services Supplemental Application. The form is available on our website (Real Estate E&O page, 'Start Here' button), or right-click the link below and select "Open link in new tab" to complete the application now.

Other Services Supplement <right-click and select "open link in new tab"
9. b. Provide gross commission income derived from the sale of these properties in the past 12 months:

Check here if none in the past 12 months
9.b. RESIDENTIAL (include this total in “Agent/Broker Owned Property Sales” under question 10 on the next page)
9.b. COMMERCIAL (include this total in “Agent/Broker Owned Property Sales” under question 10 on the next page)

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*

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

Does the applicant have any revenue derived from COMMERCIAL transactions in the past 12 months or projected?*

YesNo

List gross commission income derived from COMMERCIAL transactions:*

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

Does the applicant have any revenue derived from property management, mortgage brokering, business brokering, auctioneering, escrow, consulting, or other types of real estate services in the past 12 months or projected?*

YesNo

List gross commission income derived from OTHER SERVICES:*

	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:
*All services denoted with an asterisk (*) require a supplemental application (see next screen).

*Important* If the Applicant has revenue derived from property management, appraisals, business brokering, mortgage brokering, auctioneering, or construction/development, you must complete the Other Services Supplemental Application.

The form is available on our website (Real Estate E&O Page, 'Start Here' button), or right-click the link below and select "Open link in new tab" to complete the application now.

Other Services Supplemental Application << right-click and select "open link in new tab"

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 and sale of all Real Estate?*

YesNo

If No to #12, please explain:*
If you do not use board approved standard contract forms for the listing and sale of all Real Estate, please explain why.

13. a. In the past year, what was the average value of properties sold:*
and average value of properties appraised (if applicable):
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 you have ever had a transaction valued at $10M or more, please provide details.

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:
% dual agent:*
What percentage of the applicant's transactions involved acting as a dual agent?
% intermediary:*
What percentage of the applicant's transactions involved acting as an intermediary?
% or transactional broker:*
What percentage of the applicant's transactions involved acting as a 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 involved in asset or property preservation services on bank owned properties, please indicate whether all repairs 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 involved in asset or property rehab services on bank owned properties, please indicate whether all repairs 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?*

YesNoN/A

If No to #19, please explain:*
For bank owned properties, if you do not advise the buyer (in writing) to have the property inspected, please explain why.

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?*

YesNoN/A

If yes to #20, please provide details:*
If you or anyone from your firm has purchased properties or deeds directly from financially distressed homeowners, please provide details of the transaction(s).

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 the firm was involved in eviction services on pre-foreclosed or bank owned properties, was the complaint(s) and judgement(s) 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 #22, what is the percentage of the gross commission income derived from these services? *
If involved in cash-for-keys offers or property rehabilitation, what percentage of your income was derived from these 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 #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. During the past 5 years:
a. Has the applicant been involved in any merger, acquisition, or consolidation?*

Yes (provide details next page)No

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:

Browse Files
If Yes to 25a, upload details here Cancelof

25. b. 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 the applicant transact business in multiple states or outside of the United States?*

YesNo

If Yes, provide details including the percentage (%) 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.

IMPORTANT NOTE: The applicant’s disclosure of claim information does not indicate nor imply, in any way, that any act or omission is covered by this policy. In addition, circumstances or incidents that might reasonably be expected to be the basis of a claim MUST be reported to the applicant’s current insurer before the claim reporting period expires.

Are you currently a RealCare client for E&O insurance?*

Yes, my current E&O policy was purchased from RealCare.No, my current E&O policy was not purchased from RealCare.No, I do not currently have an E&O policy (uninsured).Unsure

NEW BUSINESS APPLICANTS ONLY MUST COMPLETE QUESTIONS 28-30
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 to Missouri residents: this question does not apply.**

YesNoI am a Missouri resident (question does not apply)
If Yes to #28, provide details on a separate sheet and upload here:

Browse Files
If Yes to #27, upload details here Cancelof

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

	Carrier	Effective Date	Expiration Date	Limit 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 and include the date, carrier, and the reason:*
If the applicant ever purchased an extended reporting period endorsement, please provide the date, carrier, and the reason.

31. Coverage Selection:
a. Limits of Liability (Per claim/Aggregate)
Claims Expense:

Claims Expense Inside the Limit (CEIL)Claims Expense Outside the Limit (CEOL)
b. Deductible
If you would like additional Limit and/or Deductible options quoted, enter them here:
Additional Limit and/or Deductible options you'd like quoted
c. Desired Policy Effective Date:*

MonthDayYear
Date
d.Current Policy Retroactive Date:

MonthDayYear
Date
UPLOAD DECLARATIONS PAGE. If you have current coverage, please attach your Declarations page here (this is NOT required unless you are a new client with RealCare).

Browse Files
Upload current dec page (this is NOT required unless you are a new client with RealCare) Cancelof

SIGNATURE PAGE

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 insurance 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: 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 or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or 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. Page 4 of 5
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.

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.
Signature*

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Please print your name:*
Title*
After signing, you must click the 'Submit' button below to submit your application.
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STANDARD APPLICATION

Make sure to save your application in case you need to continue it later:

NEW BUSINESS APPLICANTS ONLY MUST COMPLETE QUESTIONS 28-30