Foxpoint Application for Coverage - Real Estate Agent Professional Liability

APPLICATION FOR
REAL ESTATE AGENT PROFESSIONAL LIABILITY COVERAGE

NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY. COVERAGE IS WRITTEN ON A SURPLUS LINES BASIS.

RATES BELOW ARE FOR APPLICANTS POSSESSING THE FOLLOWING RISK CHARACTERISTICS:
• Generates less than $200,000 in revenues annually.   • Does not transact any Real Estate business in California
• Utilizes 3 or fewer sales personnel or independent contractors   • No involvement in Farm or Ranch Sales
• No involvement in Real Estate consulting or appraisals   • No E&O claims over the past 3 years
• Less than 25% of total commission revenues derived from commercial property transactions   • Not Domiciled in KY, NC or WA

STEP 1. DETERMINE BASE COVERAGE AND LIABILITY LIMITS DESIRED

COVERAGE CHOSEN (SELECT ONE)

Limit of Liability

Retention

Retro-Date Inception

Prior Acts
Cover

$ 500,000 / $ 500,000

$ 2,500

$ 750

$ 900

$1,000,000 / $1,000,000

$ 2,500

$ 1,000

$ 1,200

* PROOF OF PRIOR COVERAGE REQUIRED

STEP 2. OPTIONAL ENDORSEMENT

Coverage for Property Management Activies

Section "D" (Real Estate Operations) of this application must be completed.
Additional Premium: $200.00

Selected Coverage:	$0.00
Property Management Coverage Option:	$0.00
Taxes and Fees (Required):	$200.00
TOTAL AMOUNT DUE:	$0.00

A.	APPLICANT Name:
	Business Address:

	City:		State:		Zip:
	Phone:	() -	Fax:	() -
	Email:			Years in Business:
	Desired Effective Date:
	Does Applicant utilize sales personnel/independent contractors?			Yes No
If "Yes", how many?

B.	FINANCIAL AND BUSINESS INFORMATION
	a. Total commission income, last 12 months:	$
	b. Total commission income, next 12 months:	$
	c. Show services by approximate percentage:
	Service Provided	%	Service Provided	%	Service Provided	%
	Residential Real Estate Sales/Brokerage		Real Estate Consulting		Real Estate Appraisals
	Commercial Real Estate Sales/Brokerage		Property Management		Mortgage Brokering/Banking
	Ranch/Farm Real Estate Sales/Brokerage		Other (describe):

C.	PRIOR INSURANCE
	1.	Do you currently have an Errors & Omissions Insurance policy?	Yes No
		If "Yes", specify carrier:	Retroactive Date:
	2.	Has any proposed Insured ever been the subject of disciplinary action by authorities as a result of their professional activities?		Yes No
		If "Yes", please explain
	3.	Does the person to be insured have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim against him/her?		Yes No
		If "Yes", please explain
	4.	After inquiry have any claims been made against any proposed Insured(s) during the past five (5) years?		Yes No
		If "Yes", please explain


D.	REAL ESTATE OPERATIONS (To Be Completed if Property Management Coverage Desired).
	1.	Is a budget plan prepared for each property managed?		Yes No
		If "No", please explain
	2.	Is firm involved in space merchandising?		Yes No
		If "Yes", please explain
	3.	Are credit reports obtained on prospective tenants?		Yes No
		If "Yes", please explain
	4.	Are you responsible for negotiating, effecting or maintaining insurance coverage on properties managed?		Yes No
		If "Yes", please explain
	5.	Indicate percentage of management fees derived from:
		Commercial:	%
		Residential:	%
	6.	Is a budget plan prepared for each property managed?		Yes No
	7.	Do you offer any home warranty/protection plans?		Yes No
		If "Yes", please advise name of plans and percentage of transactions involving such plans:
	8.	Do you have procedures in place designed to prevent fair housing claims?		Yes No
	9.	Do you wish to have a quote including fair housing coverage?		Yes No

PAYMENT OPTIONS
	A.	Check For Full Amount Due, Payable to *Fox Point Programs, Inc.*
	B.	Credit Card:	VISA Mastercard AMEX	Card Number:
				Expiration Date:	/

	Applicant Statement & Agreement
			BY CHECKING THIS BOX, I WARRANT THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE. THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY. SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.