Please complete only the sections that apply to services performed by the Applicant or any insured.
*Property Type categories include: single family homes, 1-4 unit apartment buildings, 5+ unit apartment buildings, HOAs, office buildings, commercial properties, shopping centers, or "other."
4. Please provide the following, for the past 12 month period:
5. Indicate the percentage of loans which are:
6. What percentage of your loans:
7. Have you in the past, or do you now:
If you answered YES to any of the above (7. a-h), please explain on a separate paper on company letterhead (upload below).
If you answered YES, please explain on a separate paper on company letterhead, and upload below.
If you provide or accept funds transfer instructions via telephone, e-mail, text message or similar method of communication, the following questions are required:
If Yes, please provide the revenue and number of transactions for the past 12 months:
If Yes, please provide the following:
2. For the past 12months, please provide the amount of gross commission income (GCI) derived from the sale of properties associated with the separate business entity described in question 2 above:
3. During the past 5 years has the Applicant or any of its agents:
If Yes to 3. a., please complete a Claim Supplement for all claims. Click here for the CLAIM SUPPLEMENT
This section must be completed if coverage for the sale of Business Opportunities is requested. All questions must be answered completely.
Please provide a copy of the standard disclosure form and any other forms, waivers or disclosures used by the Applicant during the negotiation and sale of Business Opportunities.
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.
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 a person who, knowingly and with intent to defraud, presents, causes to be presented ot prepares with knowledge or belief that it will be presented to 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.
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.
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.
I understand that the information submitted in this supplementalquestionnairebecomes a part of myReal Estate ProfessionalsErrors&OmissionsInsuranceapplication and is subject to the samerepresentations and conditions.
After signing, you must click the green button below to submit your supplemental application.