What is your first name? *
What is your last name? *
What is your preferred phone number? *
What is your email address? *
What is the legal name of the applicant firm? *
Does the firm operate under DBA(s)/Trade-Name(s)? *
Please enter the DBA(s)/Trade-Name(s) below. *
What is the name of the owner/broker? *
What is the address of the applicant firm? *
Is the above address the same as the mailing address? *
What is the applicant firm’s mailing address? *
Please select the legal structure this business operates under. *
Please describe the legal structure this business operates under.
What year was the firm established?
What month/year was the firm established under the current owner?
What is the desired effective date for this coverage?
MM slash DD slash YYYY
What is the firm’s website address? (Include the prefix https://)
Please check all the states in which the applicant conducts business. (Select all that apply)
Real Estate Firm Basic Questions
Does the firm anticipate deriving more than $150,000 in gross commission income in the coming 12 months? *
Does the firm provide services involving real estate leasing or property management, commercial real estate sales or business brokerage, real estate appraisal, real estate construction development or mortgage brokerage? *
Does the applicant firm employ more than five licensed real estate agents or independent contractors (including principals and partners)? *
Does the applicant derive more than 25% of its total revenues from a single client or maintain an exclusive listing agreement with a builder or developer? *
Have you or anyone to whom this insurance would apply had their license revoked, been investigated, or been subject to any disciplinary action by any licensing board, real estate association, or other regulatory body during the past five years? *
Are you or anyone to whom this insurance would apply aware of any filed claims, acts, errors, omissions, or other circumstances which might reasonably be expected to be the basis of a claim or suit? *
Have you or anyone to whom this insurance would apply been refused insurance, been canceled, non-renewed, or declined during the past 5 years? (This restriction does not apply to cancellation for non-payment of premium.) *
Does the applicant currently maintain real estate errors and omissions insurance? *
Please upload a copy of your Declaration pages and all endorsements. This will enable us to provide prior acts coverage. *
Please select the desired coverage limit.
Please select the desired deductible.
Real Estate Firm Expanded Details
Is the principal owner a member of the National Association of Realtors?
Enter the NAR member ID?
Is the applicant independently owned and operated?
Please describe the ownership structure.
Has this firm undergone a change in ownership, name or operations including acquisition or mergers? (Note: Coverage is not provided for predecessor firms or prior principals unless approved by the insurance company.)
Please provide an explanation of the change in ownership, name or operations including acquisition or mergers.
How many principals, partners, directors or officers does this firm have?
Enter the following requested information for each principal, partner, director or officer.
Enter the following requested information for each principal, partner, director or officer.
Select the type(s) of staff employed by the firm.
Please describe the other type of staff employed by the firm.
Enter the requested information about the number of real estate agents/brokers/independent contractors at the firm.
Enter the requested information about the number of Property Managers at the firm.
Enter the requested information about the number of appraisers at the firm.
Enter the requested information about the number Referral Agents (referring only to the applicant) the firm has.
Enter the requested information about the number of Clerical/Administrative personnel at the firm.
Enter the requested information about the number of other personnel at the firm.
Enter the total numbers for Full Time, Part Time, and Inactive Employees.
General Questions
Does the firm have any one client, which represents more than 25% of the firm’s income and/or listings?
Please explain.
Does the firm or any individual or entity proposed for coverage have any exclusive listing agreement with any builders/developer?
What is the number of units sold in the past 12 months?
What is the income from the exclusive listing agreement for the past 12 months?
Please enter the property values of your five largest transactions in the last three years:
Income Section
Please select the real estate activities from which the firm derives income. (Select all that apply)
- Enter the number of transactions and all income, fees, and commissions BEFORE any split with brokers or sales people or deduction of expenses for each real estate activity.
Past Fiscal Year Income
What is the day/month when past fiscal year ended?
Enter Residential Real Estate Sales (1-4 units) information for the past fiscal year.
Enter Farm/Agriculture and/or Forestry information for the past fiscal year.
Enter Land and Lot Sales information for the past fiscal year.
Enter Commercial/Industrial/Income Property Sales information for the past fiscal year.
Enter Business Opportunities Brokerage information for the past fiscal year.
Enter Real Estate Leasing Fees information for the past fiscal year.
Enter Real Estate Consulting/Counseling information for the past fiscal year.
Enter Residential Real Estate Appraisal information for the past fiscal year.
Enter Commercial Real Estate Appraisal information for the past fiscal year.
Enter Residential Property Management Fees (1-4 units) information for the past fiscal year.
Enter Commercial or Habitational (5+ units) Property Management Fees information for the past fiscal year.
Enter Auctioneering (Real Property Only) information for the past fiscal year.
Enter Management of Associations (i.e., condominium, cooperative, homeowners) information for the past fiscal year.
Enter Mortgage Brokerage/Financial Arrangements information for the past fiscal year.
Enter Referrals information for the past fiscal year.
Enter Broker Price Opinions (BPOs) information for the past fiscal year.
What are the other real estate activities? (Please describe in detail.)
Enter Other information for the past fiscal year.
Next 12 Months: Estimates
Enter an estimate for Residential Real Estate Sales (1-4 units) for the next 12 months.
Enter an estimate for Farm/Agriculture and/or Forestry for the next 12 months.
Enter an estimate for Land and Lot Sales for the next 12 months.
Enter an estimate for Commercial/Industrial/Income Property Sales for the next 12 months.
Enter an estimate for Business Opportunities Brokerage for the next 12 months.
Enter an estimate for Real Estate Leasing Fees for the next 12 months.
Enter an estimate for Real Estate Consulting/Counseling for the next 12 months.
Enter an estimate for Residential Real Estate Appraisal for the next 12 months.
Enter an estimate for Commercial Real Estate Appraisal for the next 12 months.
Enter an estimate for Residential Property Management Fees (1-4 units) for the next 12 months.
Enter Commercial or Habitational (5+ units) Property Management Fees information for the next 12 months.
Enter an estimate for Auctioneering (Real Property Only) for the next 12 months.
Enter an estimate for Management of Associations (i.e., condominium, cooperative, homeowners) for the next 12 months.
Enter an estimate for Mortgage Brokerage/Financial Arrangements for the next 12 months.
Enter an estimate for Referrals for the next 12 months.
Enter an estimate for Broker Price Opinions (BPOs) for the next 12 months.
Enter an estimate for Other activities for the next 12 months.
What was the total gross income for the past three years? ($)
Is the firm or anyone in the firm involved with and/or providing any of the following services or activities? (Select all that apply)
Enter the requested information for the following service or activity - Environmentally Impacted Sites.
Enter the requested information for the following service or activity - Mineral / Oil / Gas Rights.
Enter the requested information for the following service or activity - Property Preservation.
Enter the requested information for the following service or activity - New Development.
Enter the requested information for the following service or activity - Management of REO Property.
Enter the requested information for the following service or activity - 1031 Exchange.
Enter the requested information for the following service or activity - Real Estate Development/Construction.
Enter the requested information for the following service or activity - Construction Management.
Enter the requested information for the following service or activity - Sale of Timeshares.
Enter the requested information for the following service or activity - Appraisal Management.
Enter the requested information for the following service or activity - Title / Abstract / Escrow.
Enter the requested information for the following service or activity - Services for Hotels, Motels, Mobile Home / RV Parks.
Enter the requested information for the following service or activity - Mortgage Banking (Other than Origination).
Enter the requested information for the following service or activity - Formation or Management of Group Investments, Syndications, Trusts and/or Partnerships.
Enter the requested information for the following service or activity - Business Valuations.
Does the firm or anyone in the firm construct, develop or own properties they sell, appraise or lease?
Which activities does the firm or someone in the firm participate in? (Select all that apply)
Please select the actions the firm or someone in the firm takes with Construction. (Select all that apply)
Please select the actions the firm or someone in the firm takes with Development. (Select all that apply)
Please select the actions the firm or someone in the firm takes when they own a property. (Select all that apply)
Please provide a description of the services and provide commission or fee income from the activities.
Does the firm or any principal engage in any other professional or real estate related enterprises or practice? (Other than the services listed in the previous questions.)
Please explain the other professional or real estate related enterprises or practices.
Residential Brokerage Details
If this is a new firm, please use anticipated income/figures for the next 12 months when answering the questions in this section.
Please indicate the average sale price of residential properties sold by this firm in the past 12 months.
What percentage of residential properties sold in the past twelve months included a home protection or warranty program?
What percentage of residential properties sold in the past twelve months included a signed property disclosure form?
Do all of the applicant’s brokers and salespersons disclose to their clients, in writing, the legal nature of their relationship? (i.e. Whether the salesperson is representing the buyer/seller or both?)
During the last 12 months, on what percentage of transactions did the firm represent both the buyer and the seller?
During the last 12 months, on what percentage of transactions did any one agent represent both the buyer and the seller?
What percentage of residential properties sold in the past twelve months were foreclosure transactions?
What percentage of residential properties sold in the past twelve months were short sales transactions?
This field is hidden when viewing the form
End previous section
Specialty Section
Please select the specialty services the firm is involved in. (Check all that apply)
Please describe the nature of the consulting/counseling services provided.
Please select the types of appraisals the firm is involved in. (Select all that apply)
Please enter the total gross income for Single Family Residences appraisals.
Please enter the key personnel and their qualifications for Single Family Residences appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Single Family Residences appraisal service, if available.
Please enter the total gross income for Multi-Family Residences appraisals.
Please enter the key personnel and their qualifications for Multi-Family Residences appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Multi-Family Residences appraisal service, if available.
Please enter the total gross income for Lots / Vacant Land appraisals.
Please enter the key personnel and their qualifications for Lots / Vacant Land appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Lots / Vacant Land appraisal service, if available.
Please enter the key personnel and their qualifications for Commercial / Industrial Property appraisals.
Please enter the key personnel and their qualifications for Commercial / Industrial Property appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Commercial / Industrial Property appraisal service, if available.
Please enter the key personnel and their qualifications for Farms / Ranches / Forestry appraisals.
Please enter the key personnel and their qualifications for Farms / Ranches / Forestry appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Farms / Ranches / Forestry appraisal service, if available.
Please enter the key personnel and their qualifications for Estate or Tax Purposes appraisals.
Please enter the key personnel and their qualifications for Estate or Tax Purposes appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Estate or Tax Purposes appraisal service, if available.
Please enter the key personnel and their qualifications for Land Development / Subdivisions appraisals.
Please enter the key personnel and their qualifications for Land Development / Subdivisions appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Land Development / Subdivisions appraisal service, if available.
Please enter the key personnel and their qualifications for Construction Phase Inspections appraisals.
Please enter the key personnel and their qualifications for Construction Phase Inspections appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Construction Phase Inspections appraisal service, if available.
Please enter the key personnel and their qualifications for Right-of-Way appraisals.
Please enter the key personnel and their qualifications for Right-of-Way appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Right-of-Way appraisal service, if available.
Please enter the key personnel and their qualifications for Personal Property appraisals.
Please enter the key personnel and their qualifications for Personal Property appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Personal Property appraisal service, if available.
Please enter the key personnel and their qualifications for Flood Zone Certifications appraisals.
Please enter the key personnel and their qualifications for Flood Zone Certifications appraisals. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the Flood Zone Certifications appraisal service, if available.
Please enter the key personnel and their qualifications for All Other appraisal services.
Please enter the key personnel and their qualifications for All Other appraisal services. (Click the plus (+) button to add rows.)
Please upload brochures and promotional material that describes the All Other appraisal services, if available.
Risk Management
Does the firm have an in-house office policy/procedures manual in place?
Does the firm have a mandatory document retention policy for all transaction files?
Does the firm use transaction management software or a transaction coordinator for all transactions?
Does the firm use local board, state association, or other association approved contracts/forms?
Please upload copies of the forms the firm uses.
Does the firm use an in-house counsel, counsel on retainer and/or risk manager?
Does the firm document each file with your verbal/written communication, recommendations, and your client’s instructions?
Does the firm have written procedures in place to notify management of problem transactions?
In the past 12 months, did at least 75% of professional staff, including independent contractors, take an approved NAR, State, or local level formal continuing education course designed to reduce real estate professional liability?
In the past 12 months, did at least 75% of professional staff, including independent contractors, take an in-house seminar conducted by an attorney or risk management consultant?
In the past 12 months, did at least 75% of professional staff, including independent contractors, take a franchisor risk management seminar?
Coverage Options
What limits of liability (each claim/annual aggregate) do you want for your coverage?
What deductible per claim do you prefer?
Do you want the First Dollar Defense coverage option, which requires an additional premium?
Previous Coverage
Do you currently have a professional liability insurance policy in force?
Please upload a copy of your current declarations pages.
Please upload a copy of your prior acts endorsement.
How many years of previous information should be provided? (Please leave the entry at 6)
Please enter the following requested information about your Real Estate Professionals Errors and Omissions Liability Insurance for the past 6 years:
In the past 6 years, has any insurance company declined, canceled, or refused to renew your firm, any predecessor firm, or anyone indicated in the application? (Missouri applicants are not required to respond.)
Please provide an explanation.
Claims
Have any claims (including violations of fair housing laws) been made against your firm, any predecessor firm, or any principle, partner, director, officer, or any of the firm’s staff?
Please upload carrier loss runs for the last six years and/or upload details of any claims.
How many claims has the firm had in the past 6 years? *
Please enter the requested details of any claims from the past six years.
Are you aware of any act, error, omission, or other circumstances, which might reasonably be expected to be the basis of a claim or suit against you, the firm, its principles, partners, directors, officers or any of its staff?
Have all matters indicated in the previous questions above been reported to the applicant's former or current insurers?
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
