Online E&O Questionnaire

Name of Applicant (Legal name/dba Name)
Street Address
City, State
Zip
County
Additional offices? Yes No
Telephone Please use (XXX)XXX-XXXX format
Fax Please use (XXX)XXX-XXXX format
E-mail
Requested Effective Date Please use MM/DD/YY format
Date firm was established Please use MM/DD/YY format
Principal Broker
Contact Person
Is the Applicant a: Corporation Partnership LLC Sole Prop Indep Cont
How did you hear about us? Internet Referral Approved Vendor Previous Client
Staff information
Full Part Inactive
Principals, Partners
Licensed Real Estate Agents
Property Managers
Appraisers
Mortgage Brokers
Licensed Assistants
Clerical/Other
Gross Income Last Fiscal Year (fees and commissions before splits)
  Number of Transactions Gross Revenues FYE 
Residential Sales $
Commercial Sales $
Leasing//Property Mgmt $
Real Estate Appraisals $
Mortgage Brokerage $
Income from Owned Property $
Other (describe below)
$
  Total Income $
Sales Information
Percentage of Properties sold with a home warranty % Warranty co.
Percentage of sales last year using Property disclosure forms %    
Percentage of sales having a professional home inspection %    
Percentage of sales from new construction %    
Claim Information
Average sale price last year $ Highest price sale $
Curr/Prev covrge Policy Period Carrier Limits Deductible Premium Retro Date
 
 
 
Have any claims been made in the last 5 years against the applicant or anyone for whom insurance is being sought? Yes No
Are you aware of any circumstances which may be expected to give rise to a claim? Yes No
During the past five years has any insurance company declined or refused to renew insurance? Yes No

Submitted by: Date: