OTHER SERVICES SUPPLEMENT

OTHER SERVICES SUPPLEMENT

Real Estate Professionals Errors and Omissions Insurance Application
Who is your insurance agent?*
If you don't know, select "Unknown"
Insurance Agent's Email (auto-fill)
auto-fill
Full Name of Applicant or Insured:*
Please complete only the sections that apply to services performed by the Applicant or any insured.

Is the applicant engaged in Property Management?*

YesNo

14. Does the Applicant have ownership interest in any properties managed?*

YesNo

If Yes, please list all owned properties, property type*, number of units, % of ownership interest, andannual rent(s) generated*

	Address (street only)	Property Type	# of Units	% Ownership	Annual Rent
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2
3
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5
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*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."

Is the applicant engaged in Mortgage Brokering?*

YesNo

Section 3: Wire Transfer Information
1. Does the applicant maintain a separate in-force Cyber Liability Policy, Crime Policy or Fidelity Bond?*

Yes -- If Yes, please provide copy of current in-force declarations page (upload below).No
If yes to #1, please upload a copy of your current declarations page

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2. Do you provide or accept funds transfer instructions via telephone, e-mail, text message or similar method of communication?*

Yes - if Yes, complete questions a, b, and cNo - if No, skip to question 3

If you provide or accept funds transfer instructions via telephone, e-mail, text message or similar method of communication, the following questions are required:
a. If Yes to #2, indicate which of the following procedures are implemented PRIOR to initiating any financial transaction.*

Calling the customer, vendor, supplier or business partner at a predetermined phone number to obtain live confirmation.Sending a text message to a predetermined number and awaiting a return text message confirmation. (note: a predetermined phone number is not a phone number that is provided with the transfer instructions)Requiring receipt of a code or password known only to the customer, vendor, supplier or business partner.
If you require receipt of a code or password, has the actual code ever been included in an e-mail communication?

YesNo
b. Are all changes to client accounts confirmed by using existing contact information PRIOR to making any changes to account information?*

YesNo
c. Is approval by more than one person required to initiate a wire transfer?*

YesNo

3. Are all staff and professionals provided with Anti-Fraud Training specific to socially engineered fraud?*

YesNo
4. Have you received any fraudulent e-mail or other communication in the past 12 months purporting to be from a customer, vendor, supplier, business partner or employee indented to direct a transfer of funds in your possession?*

YesNo
If yes, please describe:
If Yes to #4

Is the applicant engaged in Appraisals?*

YesNo

Section 4: Real Estate Appraiser Information
1. Indicate the number of appraisers who have attained professional designations related to the appraisal market: *
2. Indicate the number of appraisers who have participated in an appraisal related continuing education program in the past twelve months:*
3. Are written agreements between the Applicant and the bank or financial institution in place that outline the duties of the appraiser and the fees charged for such services?*

YesNo
4. Does the Applicant always use standard appraisal forms that comply with USPAP?*

YesNo
5. Does the Applicant perform any Right-of-Way appraisals?*

YesNo
If Yes, please provide the revenue and number of transactions for the past 12 months:

If Yes, please provide the revenue and number of transactions for the past 12 months:

	Revenue Last 12 Months	# of Transactions
Right-of-Way Appraisals

Is the applicant engaged in Auctions?*

YesNo

Section 5: Real Estate Auctioneer Information
1. Does the Applicant provide any written guarantee relating to the condition of the properties being auctioned?*

YesNo
2. Does the Applicant always put the properties to be auctioned on display for inspection prior to the auction?*

YesNo

3. Auctioning revenue: *

	Revenue Last 12 Months	# of Transactions
Auctioning of Real Property

Is the applicant engaged in Construction/Development?*

YesNo

Section 6: Construction/Development Ownership Interest Information
1. Has the Applicant, or any of its agents, sold or listed for sale any properties that were developed or constructed by a separate business entity owned by the firm, any of its agents or the spouse or domestic partner of an agent or owner?*

YesNo

If Yes, please provide the following:
a. Name of the business entity*
b. Percentage of the business entity owned by the firm or agent:*
If none, enter "0%"
c. Percentage of the business entity owned by the spouse of domestic partner:*
If none, enter "0%"
d. Number of years the entity has been in business:*
e. Number of years the entity has operated in the same area:*
f. Number of years of development/construction experience key personnel have:*
g. Types of properties developed or constructed by the business entity:*

ResidentialCommercial
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:
Residential Property GCI:*
If none, enter "$0"
Commercial Property GCI:*
If none, enter "$0"
3. During the past 5 years has the Applicant or any of its agents:
a. Had any claims made against them involving the entity mentioned in question 1a. above?*

YesNo
If Yes to 3. a., please complete a Claim Supplement for all claims. Click here for the CLAIM SUPPLEMENT
b. Have knowledge of any act or omissions which might reasonably be expected to be the basis of a claim against them involving the entity mentioned in question 1a. above?*

YesNo
If Yes to 3. b., provide details below:

Is the applicant engaged in Business Brokering?*

YesNo

Section 7: Business Brokerage Information
This section must be completed if coverage for the sale of Business Opportunities is requested. All questions must be answered completely.

1. Please provide the Name and the years of business brokerage experience for each agent or broker who is involved in the sale of business opportunities:*

	Agent or Broker's Name	Years of Business Brokering Experience
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2
3

2. Is the Applicant, or the agent or broker responsible for the sale of the business, involved in the valuation of the business being sold?*

YesNo
3. Does the Applicant disclose to the purchaser in writing that there is no certainty or assertion of any future business value or income?*

YesNo
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.
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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. Cancelof
4. Does Applicant provide a written recommendation that each party retain an attorney and an accountant for the purpose of performing a due diligence review; including evaluation of the income, expenses and feasibility of the sale/purchase of the business operations?*

YesNo
5. Does Applicant have a written policy prohibiting agency personnel from making recommendations regarding attorneys and accountants selected?*

YesNo
6. Briefly describe the number and types of Business Opportunities arranged, negotiated or sold by the Applicant within the past three years:*

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.

SIGNATURE PAGE
Print Name*
Title*
Signature*

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Email Address
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After signing, you must click the green button below to submit your supplemental application.
Should be Empty:

	# of Units / Square Footage	% of Property Mgmt Income (this column must add up to 100%)
Single Family Homes
1-4 Unit Condos/Apartments
5+ Unit Condos/ Apartments
Home Owners' Associations
Shopping Centers
Office Buildings / Commercial
Other

OTHER SERVICES SUPPLEMENT

Section 1: Property Manager Information

Section 2: Real Estate Mortgage Broker Information

Section 3: Wire Transfer Information

Section 4: Real Estate Appraiser Information

Section 5: Real Estate Auctioneer Information

Section 6: Construction/Development Ownership Interest Information

Section 7: Business Brokerage Information

	Lender Name	% used
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