Cotizacion de Real Estate Brokers

NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS LIMITED TO LIABILITY FOR WRONGFUL ACTS COMMITTED SUBSEQUENT TO THE RETROACTIVE DATE, IF APPLICABLE, FOR WHICH CLAIMS ARE FIRST MADE AGAINST THE INSURED WHILE THE POLICY IS IN FORCE AND WHICH ARE REPORTED TO THE COMPANY NO LATER THAN SIXTY (60) DAYS AFTER THE TERMINATION OF THE POLICY. THE LIMITS OF LIABILITY AVAILABLE TO PAY DAMAGES, INCLUDING JUDGMENT OR SETTLEMENT AMOUNTS, SHALL BE REDUCED BY AMOUNTS INCURRED FOR CLAIMS EXPENSES. FURTHER NOTE THAT AMOUNTS INCURRED FOR CLAIMS EXPENSES AND DAMAGES SHALL ALSO BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.

Name*

First Name Last Name

Address

Mailing Address Ciudad Estado / Provincia / Región ZIP / Código Postal

Policy Number

Email

Phone

Professional office location

Percentage owned

List your qualifications

License Type/Title

Year License was Issued

Active or Inactive

Please indicate the number of personnel in each of the following categories

Principals, partners, directors, officers and professional employees

(Professional Employees are employees performing professional services on behalf of the Applicant)

Non-professional (clerical) employees

Independent contractors performing professional services on behalf of the Applicant

Does the Applicant use subcontractors?

Yes
No

What percentage of the Professional Services indicated above is subcontracted out?

Does the Applicant receive a copy of the subcontractor’s errors and omissions or professional liability insurance policy?

Yes
No

Do contracts with subcontractors have hold harmless or indemnity agreements that benefit the Applicant?

Yes
No

Applicant is

Individual
Partnership
Corporation
Other(Specify)

Gross Revenue

Past 12 Months

Current 12 Months

Projection for Next Year

Please provide a percentage distribution of the following services, total must equal 100%:

Residential

Real Estate Appraisal

Farms

Property Management

Land and Lots

Auctioneering Services

Commercial & Industrial

Mortgage Brokers

Co Brokerage

Real Estate Leasing Fees

Real Estate Consulting

Others

Do any principals, directors, officers, partners, professional employees or independent contractors of the Applicant or any of the entities identified in Question 2 for which coverage is desired, have knowledge or information of any act, error, omission, breach of professional duty, or any other circumstance which might reasonably be expected to give rise to a claim?

Yes
No

Has the Applicant or any of its predecessors in business, subsidiaries or affiliates, or any of the principals, directors, officers, partners, professional employees or independent contractors ever been the subject of a disciplinary action as a result of professional activities?

Yes
No

During the past five years, have any claims been made or legal action brought against the Applicant or any of the entities identified in Question 2 for which coverage is desired, or any predecessors in business, subsidiaries, affiliates or any principal, director, officer or professional employee?

Yes
No

Has the Applicant reported the matters listed in Question 8 a-c to its current or former insurance carrier?

Yes
No

I Accept

NOTE: If any such claims exist, or any such facts or circumstances exist which could give rise to a claim, then those claims and any other claims arising from such facts or circumstances are excluded from the proposed insurance.

Aviso Anti Fraude:

Cualquier persona que a sabiendas y con la intención de defraudar presente información falsa en una solicitud de seguro o, que presentare, ayudare o hiciere presentar una reclamación fraudulenta para el pago de una perdida u otro beneficio o, presentare más de una reclamación por un mismo daño o perdida, incurriría en delito grave y convicto que fuere, será sancionado, por cada violación con pena de multa no menor de cinco mil ($5,000) dólares, ni mayor de diez mil ($10,000) dólares o pena de reclusión por termino fijo de tres (3) anos, o ambas penas. De mediar circunstancias atenuantes, podrá ser reducida hasta un mínimo de dos (2) anos. Artículo 27.320 de la ley #18 de 2004

SUSCRIBETE A NUESTRO NEWSLETTER

TRABAJA CON NOSOTROS