York Jersey Underwriters Agency Inc. - Mortgage Field Services Form

* Required Fields

Applicant Name:*

Business Name:

Email Address:*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

A. List below by names the Mortgage Field Service Companies, Banks, Mortgage Companies or Realtors for whom you perform mortgage field services and the percentage of income derived from these companies:

1*

	*Company*	*Percentage of Income (%)*
1
2
3
4
5

B. List below by names the Mortgage Field Service Companies, Banks, Mortgage Companies or Realtors for whom you perform mortgage field services and the percentage of income derived from these companies:

	*Company*	*Percentage of Income (%)*
1
2
3
4
5

2. A. Estimated Annual Gross Income for the next 12 months*

B. Estimated Annual Gross Income for the last 12 months*

3. Provide a percentage breakdown of your annual receipts, falling within the following categories:

a. Residential Property Inspections (%)

f. Vacant Property Reports (%)

b. Delinquent Borrower Interviews (%)

g. Property Preservation Services (%)

c. Commercial Property Inspections (%)

h. Property Preservation and Repair Estimates (%)

d. Insurance Loss Draft Inspections (%)

i. Property Rehabilitation Service (%)

e. Evictions (%)

j. Merchant Site Verifications (%)

4. Provide percentage of work performed on:

Private Residences (%)

Commercial Properties (%)

5. If you perform operations other than those listed in question 3, provide a description of these operations and applicable annual receipts.

6. Do you use independent Contractors?

YesNo

If yes, provide a description of the operations they perform.

Estimated annual contract costs:

Do you require they carry Liability Insurance limited at least equal to your own?

YesNo

7. Do you obtain Certificates of Insurance?

YesNo

8. Are you required to provide Hold Harmless Agreements?

YesNo

If yes, provide a sample of the most common wording.

9. Do you perform and services or work in New York? *

YesNo

If yes, Does any work/services provided involve any roofing work or work outside at height regardless of whether done by the applicant or sub-contracted out?

YesNo

If yes, describe

10. Provide a description of any contracting, maintenance or service equipment used in the performance of your service.

11. Provide number of:

Officers:

Partners:

Employees:

12. Do you perform reference and security checks on all employees?

YesNo

13. Do you have formal training procedures for employees that perform inspections and/or interviews?

YesNo

If yes describe:

14. Years in business:*

15. Phone #*

Fax #

16. Type of business:*

If Other Describe:

17. Current Insurance Company:*

Type of Insurance:

Retroactive Date:

Current Premium:

Type a question

18. Do you use day laborers?*

YesNo

Loss History

has not had any claims made/ suits filed, or circumstances notified that I am/ we are aware could become claims against me/ us in the last thirty six months. In the case of a corporation, diligent inquiry must be made of all persons that could have knowledge of claims or circumstances and this declaration is made on behalf of all such persons.*

Type in your business name or name

Enter All Claims, Occurrences, or Circumstances that may give rise to claims for the prior thirty six months

Check here if noneCheck here if emailing loss summary

Date of Occurrence

Type and description of claim,
Occurrence or Circumstances

Amount Paid

Amount Reserved

1

2

3

4

5

SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE

YOU HAVE THE RIGHT UNDER THE ACT TO SELECT OR REJECT THIS TERRORISM COVERAGE. YOU MAY SELECT THIS COVERAGE BY INDICATION YOUR SELECTION AND PAYING THE ADDITIONAL PREMIUM AS INDICATED BELOW. YOU MAY ALSO CHOOSE TO DECLINE THIS COVERAGE, BY INDICATING YOUR CHOICE BELOW, IN WHICH EVENT YOU WILL NOT BE CHARGED ANY ADDITIONAL PREMIUM. IF YOU DECLINE THIS COVERAGE, YOU WILL NOT BE COVERED FOR LOSSES ARISING FROM ANY ACT OF TERRORISM, INCLUDING CERTIFIED ACTS OF TERRORISM UNDER THE TERRORISM INSURANCE ACT OF 2002.

I hereby acknowledge that I have been notified that under the Terrorism Risk Insurance Act of 2002, that any losses caused by certified acts of terrorism, should I elect to purchase such coverage, will be partially reimbursed by the United States government and I have been notified of the amount of additional premium attributable to such coverage.

(please select one)*

I hereby elect to purchase coverage for certified Acts of Terrorism for the Additional Terrorism Risk Premium shown in this notice.I hereby elect NOT to purchase coverage for certified Acts of Terrorism and understand that I will have no coverage for losses arising from any certified acts of terrorism.

DECLARATION

You must read this before signing below.
To the best of my knowledge and belief the information provided in connection with this proposal, whether in my own hand or not, is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact will entitle Underwriters to avoid this Insurance.
(A material fact is one likely to influence acceptance or assessment of this proposal by Underwriters. If you are in any doubt as to whether a fact is material or not you must disclose it in the space below).

Policyholder's/Applicants Digital Signature: (Please type name)*

Date:

Please indicate your selection of rejection of the option to purchase the coverage described in the space indicated above; digitally sign and date the notice and submit. Please print a copy of the completed notice for your records. Please include any documents pertinent to this application:

Upload File:

List all companies that will require certificates of Insurance from you.

Loss History

SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE

DECLARATION