CLAIM SUPPLEMENT

CLAIM SUPPLEMENT

REAL ESTATE ERRORS & OMISSIONS INSURANCE APPLICATION
Who is your insurance agent?:*
If you don't know, select "Unknown"
Insurance Agent's Email (auto-fill)
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1. Full Name of Applicant or Insured:*
2. Full Name of Individuals or Firm involved in the claim: *
3. Full Name of Claimant:*
4. Indicate whether:*

IncidentClaim / Suit
5. Date you became aware of the alleged error:*

MonthDayYear
Date
6. Date you reported to your insurance carrier:*

MonthDayYear
Date
7. Name of Insurance Company:*
8. Additional Defendants:
9. If CLOSED: Complete next four fields.
Indicate date closed:

MonthDayYear
Date
Total Amount Paid:
Of the total amount paid, how much was for legal expenses?:
What was your deductible?
10. IF PENDING: Please upload (below) or email a copy of the suit papers, or answer all questions below.
Claimant's settlement demand:
Defendant's offer for settlement:
Insurer's loss reserve:
Is the claim in suit?

YesNo
If Yes, what is the amount asked in summons?
Limit of Liability & Deductible

Limit of LiabilityDeductible
11. Provide a brief description of the claim; indicate the alleged error, description of events leading to the claim, type and extent of injury or damage alleged and what policies or procedures have been implemented to prevent a reoccurrence or similar situation (upload separate sheets as needed):*
Upload Additional Documents

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Title*
Signature*

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Email
example@example.com
After signing, you must click the green button below to submit your claim form.
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