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1a. Name of Applicant
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(List all names, trade names or DBA's under which the Applicant Operates)
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1b. Date Firm Was Established: Address:
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(Or Anticipated Start Date) (Street No. and Name)
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City: County: State: Zip Code:
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2a. Email: 2b. Telephone 2c. Fax
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3a. Do you currently have an E&O Policy? Yes No
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(If you are starting a new company, your previous Broker's E&O policy does not apply)
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3b. If yes, please provide us with the following information, and, a copy of your current Declarations Page:
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Current Carrier Effective Date
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Deductible $ Premium $ Retroactive Date
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4. Preferred Deductible Option(s): $2,500 $5,000 $10,000 $25,000
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5. Preferred Limits of Liability Option(s): $500,000/$500,000 $1,000,000/$1,000,000
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6a. Number of Brokers/Agents (Including Broker Owners):
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6b. Are these C.A.R. members? YES NO
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7. Please complete the following information for each Principal/Partner/Director/Officer/Owner:
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8. GROSS COMMISSION INCOME
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9. What Percentage of Standard Board/State Approved Contracts is used? %
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10. Include the Approximate Percentage of Dual Agency Transactions Your Firm performs %
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11. Do you perform services connected with a Real Estate Developer/Construction Company? Yes No
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(If yes, please explain.)
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12. Have any Errors or Omissions Claims been made against any of the Applicants during the Past Five Years?
YES NO
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(If yes, please provide us with all details of each claim and currently-valued loss reports - covering the previous five years.)
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(Authorized Representative Signature) (Date)
* Entering name works as an electronic signature
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*Please note - This application will be used for quoting purposes only. A formal indication will be subject to the receipt and review of a fully completed application and
executed Warranty Letter – Confirming No Known Claims.
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