Real Estate Errors & Omissions Insurance
Professional Liability
(Pennsylvania)

You can also print the actual application, and mail it to us. See Application
 

Applicant Name: 
Contact Name: 
Mailing Address: 
City: 
   State: 
Phone Number: 
     Fax: 
E-Mail Address: 
Date business was established Date licensed as a broker Date licensed as an agent
 
Business Organization Applying for coverage as a 
Firm  /  Individual
If individual, are you the broker/owner? Yes / No

 
Has applicant or predecessor firm at any time in the past or present, engaged in any business venture outside the scope of a Real Estate Organization, including but not limited to, construction, property development, mortgage banking, mortgage brokering or insurance?
Yes /  No
If "YES", please answer the following questions:
a) Please advise details:
b) Has more than 10% of your real estate firm's income been derived from property development or construction activities?
Yes / No
c) Do you understand that there is NO coverage under the proposed policy for Loss of Defense cost in connection with claims involving the construction, development, sale or resale of real property developed or constructed by any applicant?
Yes / No

Total number of each category (list each person only once, identifying their primary area of responsibility:
Full Time Part Time Category
Real Estate Agents/Brokers/Independent Contractors
Property Managers
Appraisers
Morgage Brokers
Real Estate Assistants
Clerical Personnel
Other: (describe) 

Applicant's Gross Revenue for the past 12 months (all fees and commissions before expenses, including any fees, commissions, or bonuses payable to employees and independent contractors).  Indicate gross revenue derived from the sale of property, NOT the value of properties sold.
(residential real estate means any property containing a single-family dwelling or multiple-family dwellings of up to 4 units.  Any property over 4 units is considered commercial)

Description
 Gross Income
Last 12 months		 Number of Transaction Projected Income
Next 12 months
Residential including owned farms
Commercial, including residential properties over 4 units
Property Management Fees
     Residential

     Commercial

Real Estate Appraisal fees (complete addendum if over 35%)
     Residential

     Commercial

     Mortgage Brokers

     Other

Percentage of home warranties sold on all transactions in the past 12 months: 

Is more than 25% of units sold worth over $ 250,000? Yes  / No
   If "YES", what is the average value of units sold that are over $ 250,000: 

Is more than 10% of applicant's commission income derived from the sale of real estate at any one location or development?
Yes / No   If "YES", please provide details: 

Does your firm have an in-house Policy Procedures Manual? Yes / No

Has the applicant or any past or present staff member had their license revoked, or been subject to disciplinary action by any Real Estate Association, State Licensing Board or any other regularory body? Yes / No
If "YES", please provide details:

Current Insurance

E & O Insurance Co Expiration
Date		 Limit of Liability Premium Deductible

During the past 5 years, has any insurance company declined, cancelled or refused renewal or similar insurance on behalf of this applicant, predecessor firm or anyone for whom this insurance will apply?  Yes /  No
If "YES', please explain....

Does your firm maintain General Liability Insurance?  Yes /  No

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway      Murrysville, PA. 15668-1890
(724) 327-8474                                (fax) 327-7911
Toll Free: 1-800-977-2999                (fax) 1-888-800-0034
 

http://www.McGrathInsuranceGroup.com                                McGrathInsurance@verizon.net