Click here to print out an application

L I N S I N, S H E R M A N   A S S O C I A T E S

APPLICATION

REAL ESTATE BROKERS & AGENTS
ERRORS & OMISSIONS LIABILITY INSURANCE

THE INSURANCE COVERAGE FOR WHICH YOU ARE APPLYING IS WRITTEN ON A CLAIMS MADE POLICY. THEREFORE, ONLY CLAIMS WHICH ARE FIRST MADE AGAINST YOU DURING THE POLICY PERIOD AND WHICH ARE BASED ON A WRONGFUL ACT BY YOU WHICH FIRST OCCURS DURING THE POLICY PERIOD OR RETROACTIVE PERIOD, IF ANY, ARE COVERED. “CLAIM” MEANS A DEMAND FOR MONEY OR SERVICES, INCLUDING THE SERVICE OF SUIT OR INSTITUTION OF ARBITRATION PROCEEDINGS AGAINST THE INSURED, ALLEGING A WRONGFUL ACT, AS DEFINED IN THE POLICY.
1. NAME OF APPLICANT DATE
(List all names, trade names or DBA’s under which the Applicant Operates)
PRINCIPAL BUSINESS ADDRESS:
(Street No. and Name)
City County State Zip
2. DOES APPLICANT HAVE ANY OTHER OFFICE LOCATIONS? YES NO
(List all secondary or foreign office locations. This application should reflect information pertaining to all of these offices.)
3a. BUSINESS TELEPHONE: 3b. FAX#
3c. EMAIL:
4. APPLICANT IS: CORPORATION PARTNERSHIP INDIVIDUAL OTHER
5. DATE FIRM WAS ESTABLISHED
(MONTH / DAY / YEAR)
6. HAS THE NAME OF APPLICANT CHANGED OR HAS ANY OTHER FIRM OR ORGANIZATION MERGED WITH OR BEEN ACQUIRED BY APPLICANT IN THE LAST 5 YEARS? YES NO
IF YES, PLEASE DESCRIBE FULLY.
7. IS THERE ANY PENDING CHANGE IN THE NAME OF APPLICANT OR PENDING ACQUISITION OR MERGER?
YES NO IF YES, PLEASE DESCRIBE FULLY.
8. LIMIT OF LIABILITY: PER OCCURRENCE ANNUAL AGGREGATE
$ $
9. DEDUCTIBLE $5,000 $10,000 $25,000 $50,000 Other
10. EFFECTIVE DATE REQUESTED:
11. DO YOU WANT COVERAGE FOR WRONGFUL ACTS OCCCURRING PRIOR TO THE EFFECTIVE DATE REQUESTED ("PRIOR ACTS")? YES NO
IF YES RETROACTIVE DATE REQUESTED
12a. STAFF (COUNT EACH INDIVIDUAL ONLY ONCE. "LICENSED" REFERS TO DRE/LICENSE)
  LICENSED UNLICENSED
PRINCIPALS:
INDIVIDUAL AGENTS/BROKERS:
FULL TIME:
PART TIME:
EMPLOYEES:
*BROKER ASSISTANTS:
TOTALS:
*COVERAGE DESIRED: YES NO
12b. PLEASE COMPLETE THE FOLLOWING INFORMATION FOR EACH PRINCIPAL / PARTNER / DIRECTOR / OFFICER / OWNER:
NAME TITLE DATE FIRST LICENSED YEARS EXPERIENCE YEARS WITH APPLICANT
13. GROSS COMMISSION INCOME - (GCI) & CLOSED TRANSACTIONS
  PAST FY
(ACTUAL) 		CURRENT FY
(PROJECTED) 		NEXT FY
(PROJECTED)
  #TRANSACTIONS GCI #TRANSACTIONS GCI #TRANSACTIONS GCI
RESIDENTIAL REAL ESTATE
COMMERCIAL REAL ESTATE
MORTGAGE BROKERAGE
PROPERTY MANAGEMENT
ESCROW
BUSINESS BROKERAGE
LEASING
OTHER (DESCRIBE)
TOTALS
14. DOES ANY CLIENT REPRESENT MORE THAN 25% OF THE FIRM'S INCOME? YES NO
15. SERVICES FOR PROPERTIES OWNED / DEVELOPED BY ANY INSURED.
  • a) INCLUDED IN CURRENT / INTENDED OPERATIONS: YES NO
  • b) INCOME DERIVED FROM PAST FY: $
  • c) IS COVERAGE DESIRED: YES NO
16. IS THE APPLICANT CONTROLLED BY OR OWNED BY, OR DOES THE APPLICANT CONTROL OR OWN, ANY OTHER FIRM OR BUSNESS? YES NO
(IF YES, PLEASE EXPLAIN)
17. IS THE APPLICANT OR ANY SUBSIDIARY, PARENT OR OTHER RELATED ORGANIZATION ENGAGED IN:
  • a) REAL ESATE DEVELOPMENT OR CONSTRUCITON? YES NO
  • b) MORTGAGE BANKING? YES NO
  • c) THE FORMATION, MANAGEMENT OR ORGANIZATION OR GROUP INVESTMENT SYNDICATIONS (INCLUDING LIMITED PARTNERSHIPS, GENERALPARTNERSHIPS, REAL ESTATE INVESTMENT TRUSTS OR CORPORATIONS) YES NO
  • d) ANY BUSINESS ENTERPRISE OR PROFESSIONAL PRACTICE OTHER THAN REAL ESTATE SALES, PROPERTY MANAGEMENT, APPRAISAL OR COUNSELING? YES NO
IF YES TO 17a, b, c, or d, PLEASE EXPLAIN ON A SEPARATE SHEET. INCLUDE A DESCRIPTION OF SERVICES PERFORMED, PROPERTY VALUESINVOLVED AND FEES RECEIVED.
18. ARE ANY PRINCIPALS, PARTNERS, DIRECTORS OR REAL ESTATE AGENTS / BROKERS OF THE APPLICANT FIRM ENGAGED IN ANY ACTIVITIESDESCRIBED IN QUESTION 17a, b c, OR d? YES NO
19. LIST ALL STATES WHERE THE APPLICANT OPERATES:
20. DO YOU BELONG TO A BOARD OF REALTORS? YES NO
21. ARE YOU A PARTICIPANT IN A MULTIPLE LISTING SERVICE? YES NO
22. ARE YOU A MEMBER OF ANY NATIONAL FRANCHISE, REFERRAL OR RELOCATION ORGANIZATION?
YES NO
IF YES, PLEASE INDICATE NAME(S):
23. DO YOU USE STANDARD CONTRACT FORMS APPROVED BY THE CALIFORNIA ASSOCIATION OF REALTORS? YES NO
24. DO YOU ADVISE OR ARRANGE FINANCING FOR YOUR CUSTOMERS? YES NO
IF YES, DESCRIBE SUCH ACTIVITIES:
25. INCLUDE THE APPROXIMATE PERCENTAGE OF PROPERTIES SOLD IN THE PAST 12 MONTHS WITH A HOME PROTECTION OR WARRANTY PROGRAM. %
26. HAVE ANY ERRORS AND OMISSIONS CLAIMS BEEN MADE DURING THE PAST FIVE YEARS AGAINST THE APPLICANT OR ANYONE INDICATED INQUESTION 12? YES NO
IF "YES" INCLUDE INSURANCE CARRIER(S) CURRENTLY VALUED LOSS REPORTS FOR THE PAST FIVE (5) YEARS.
27. IS THE APPLICANT AWARE OF ANY ACT, ERROR, OMISSIONS OR OTHER CIRCUMSTANCES WHICH MIGHT REASONABLY BE EXPECTED TO BE THEBASIS OF A CLAIM OR SUIT AGAINST THE APPLICANT OR ANYONE INDICATED IN QUESITON 12? YES NO
28. DURING THE PAST SIX YEARS, HAS ANY INSURANCE COMPANY DECLINED, CANCELED, RESCINDED, OR REFUSED TO RENEW FOR THE APPLICANTOR ANYONE INDICATED IN QUESTION 12, A POLICY OF REAL ESTATE AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE? YES NO
IF YES, PLEASE EXPLAIN.
29. HAS THE APPLICANT OR ANY PERSON INDICATED IN QUESTION 12 HAD HIS LICENSE REVOKED OR SUSPENDED OR BEENFORMALLY REPRIMANDED OR SUBJECT TO DISCIPLINARY ACTION? YES NO
IF YES, PLEASE EXPLAIN.
30. PLEASE COMPLETE THE FOLLOWING FOR THE APPLICANT AND ANY PREDECESSOR FIRMS WITH RESPECT TO REALESTATE AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE FOR THE PAST FIVE YEARS, INCLUDING ANYEXTENDED CLAIMS REPORTING PERIOD ("TAIL") COVERAGE. IF NO PAST COVERAGE, INDICATE NONE. PLEASE SHOW EACHINSURANCE YEAR ON A SEPARATE LINE.
POLICY PERIOD
(MONTH / DAY / YEAR TO
(MONTH / DAY / YEAR) 		INSURANCE COMPANY
(NOT AGENT) 		LIMIT OF LIABILITY
EACH CLAIM /
ANNUAL AGGREGATE 		DEDUCTIBLE ANNUAL PREMIUM
DATE: PHONE:
SIGNATURE:
* Entering name works as an electronic signature		 TITLE:
LINSIN, SHERMAN ASSOCIATES
RAFAEL NORTH, SUITE 250
185 NORTH REDWOOD DRIVE
SAN RAFAEL, CA 94903
TEL: (415) 479-9988
FAX: (415) 479-9966
E-MAIL: j.davis@linsinsherman.com

 Home | About Us | C.A.R. Endorsed Program | FAQ