/ UNITED STATESLIABILITY INSURANCE GROUP
A BERKSHIREHATHAWAY COMPANY
USLI.COM
888-523-5545 /
RealEstateErrorsOmissions-AllStates
ApplicantmayqualifyforanINSTANTQUOTEbycompletingSectionIbelow.SectionIIanswers(andSectionIIIifpackageisdesired)willbe requiredpriortobindingandaresubjecttounderwritingapproval.
I.INSTANTQUOTEINFORMATION
Instantquoteisnotavailableforaccountswithlossesinthepast5years.Ifthereisalosshistory,pleasecompleteSectionI.andsubmitdetailsinaclaim supplement.
Applicant’sname:
Locationaddress: / Sameasmailing
City: / State: / Zipcode:
Webaddress: / E-mailaddressofprimarycontact:
Totalnumberofrealestateagents/brokers/propertymanagers/independentcontractors: Fulltime / Parttime
Grosscommissionincomebreakdown:
Residentialsales$ / Commercialsales$ / Rawlandsales$
Residentialpropertymanagement/leasing$ / Commercialpropertymanagement/leasing$
Residentialvacantlandsales$ / Commercialvacantlandsales$
Appraisals/Brokerpriceopinions$ / Consulting$
Other(pleasespecify)$
Istheapplicantaffiliatedwithafranchise? / Yes No
II. UNDERWRITINGINFORMATION
1.Hastheapplicant’sprincipalormanagingpartnerbeeneitheralicensedagentforaminimumoffiveyearsor alicensedbrokerforaminimumoftwoyears? Datebusinessestablished.
2.Pleaseadviseifmorethan10%oftheincomeisderivedfromanyofthefollowing:
a)construction/developmentactivities / Yes No
b)sale,managementorleasingofpropertiesconstructed/developedbytheapplicantoranyrelatedentity / Yes No
c)fromthesaleofagentownedproperties / Yes No
d)saleofrealestateatanyonelocationordevelopment(subdivision)oronebuilder/developer / Yes No
e)fromrealestateauctioneering,businessbrokeringand/orreferralservices / Yes No
3. Ismorethan25%ofincomederivedfromforeclosuresales/REO/shortsales? / Yes No
4. Doyouderiveincomefromanyactivitiy/professionotherthanfromthescopeofarealestateorganization? / Yes No
If“Yes,”pleaseadvisedetails:
5. Domorethan50%oftheapplicant’stransactionsinvolveservicesasadualagent? / Yes No
6. Doestheaveragevalueofpropertiessoldexceed$600,000? / Yes No
7. Expiringinsuranceinformation: / Carrier: / Limits: / Retention:
Premium: / Retroactivedate:
(Attachastatementofdetailsforall“yes”answerstothefollowingquestions)
8. Hasanypersonproposedforinsurancehadhis/herlicenserevoked,suspended,beenfined,orbeensubjecttoany disciplinaryactionorinvestigationbyanyrealestateassociation,statelicensingboardorotherregulatorybody? / Yes No
9. Hastheapplicantbeenthesubjectofanyreportings/complaintstoaBetterBusinessBureau,Federal TradeCommissionoranyotherconsumerprotectiongroup? / Yes No
10. HasanypolicyforRealEstateAgentsE&OInsuranceeverbeencancelledornon-renewed?
(DonotanswerifapplicantislocatedinMissouri) / Yes No
11. Withinthelastfiveyears,hasanyclaimbeenmadeorsuitbroughtagainsttheapplicant,itspredecessor(s)in business,oranyofitspresentorformerowners,partners,officers,directors,employeesorindependent contractors?If“Yes,”completeUSLIClaimSupplementforeachclaim. / Yes No
12. Is any owner, partner, officer, director, employee, or independent contractor aware of any circumstance, allegation, contention or incident which may result in a claim being made against the applicant, its predecessor(s) in business, or any of its present or former partners, owners, officers, directors, employees or independent contractors? / Yes No
If“Yes,”completeUSLIClaimSupplementforeachclaim.
III. BUSINESSOWNERSPACKAGEINSURANCE
  1. Hastheapplicanthadanygeneralliabilityorpropertyclaimspaid,reserved,orpendinginthelastfiveyears?
/ Yes No
If“Yes,”providedetails:
  1. Doestheapplicantwantanyadditionalinsured(s)includedongeneralliability?
/ Yes No
If“Yes,”attachdetailsincludingname,relationshiptoapplicantandaddress.
  1. Personalpropertylimitincludingcomputerhardware(at80%coinsurance/replacementcost):
/ Yes No
  1. Buildingcharacteristics:

a)Arefunctioningburglaralarmspresent? / Yes No
b)Isallelectricalwiringconnectedtofunctionalandoperationalcircuitbreakers? / Yes No
c)Aretherefunctioningsmokeandheatdetectorsinallunitsand/oroccupancies? / Yes No
d)Isaluminumwiringpresentinthebuilding? / Yes No
  1. Propertyprotectionclass(1-10):

  1. Buildingconstruction(pleasecheckone):

Frame-Bldg.ismadefromawoodframe(2x4’s/veneers)
Joistedmasonry-Outsidewallsareconstructedwithbricks/cinderblocks.Roofismadeofwood.
Masonrynon-combustible-Sameasjoistedmasonryexceptroofissteel.
Fireresistive-Structuralsteelframing,reinforcedconcreteoutside/loadbearingwalls.
IV. ADDITIONALAPPLICANTINFORMATION
Applicant’smailingaddress:
City: / State: / Zip:
ArizonaNotice:Misrepresentations,omissions,concealmentoffactsandincorrectstatementsshallpreventrecoveryunderthepolicyonlyif themisrepresentations,omissions,concealmentoffactsorincorrectstatementsare;fraudulentormaterialeithertotheacceptanceoftherisk, ortothehazardassumedbytheinsurerortheinsureringoodfaithwouldeithernothaveissuedthepolicy,orwouldnothaveissuedapolicy inaslargeanamount,orwouldnothaveprovidedcoveragewithrespecttothehazardresultingintheloss,ifthetruefactshadbeenmade knowntotheinsurerasrequiredeitherbytheapplicationforthepolicyorotherwise.
MinnesotaNotice:Authorizationoragreementtobindtheinsurancemaybewithdrawnormodifiedonlybasedonchangestotheinformation containedinthisapplicationpriortotheeffectivedateoftheinsuranceappliedforthatmayrenderinaccurate,untrueorincompleteany statementmadewithaminimumof10daysnoticegiventotheinsuredpriortotheeffectivedateofcancellationwhenthecontracthasbeenin effectforlessthan90daysorisbeingcanceledfornonpaymentofpremium.
MissouriRhodeIslandDisclosureNotice:IunderstandandacknowledgethatasrespectsDiscriminationandLockBoxcoveragethatClaimsExpensesareapartoftheLimitofLiability.ThismeansthatClaimsExpenseswillreducemylimitsofinsuranceandmayexhaust
themcompletelyandshouldthatoccur,IshallbeliableforanyfurtherClaimsExpenses.ClaimsExpensesareasdefinedinSectionVII.Ialso understandthattheLimitofLiabilityfortheExtendedReportingPeriod,ifapplicable,shallbeapartofandnotinadditiontothelimitspecified inthePolicyDeclarations.
NewYorkDisclosureNotice:Thispolicyiswrittenonaclaimsmadebasisandshallprovidenocoverageforclaimsarisingoutofincidents, occurrencesorallegedWrongfulActsorWrongfulEmploymentActsthattookplacepriortoretroactivedate,ifany,statedonthedeclarations. ThispolicyshallcoveronlythoseclaimsmadeagainstaninsuredwhilethepolicyremainsineffectforincidentsreportedduringthePolicy PeriodoranysubsequentrenewalofthisPolicyoranyextendedreportingperiodandallcoverageunderthepolicyceasesupontermination
ofthepolicyexceptfortheautomaticextendedreportingperiodcoverageunlesstheinsuredpurchasesadditionalextendreportingperiod coverage.Thepolicyincludesanautomatic60dayextendedclaimsreportingperiodfollowingtheterminationofthispolicy.TheInsuredmay purchaseforanadditionalpremiumanadditionalextendedreportingperiodof12months,24monthsor36monthsfollowingtheterminationof thispolicy.Potentialcoveragegapsmayariseupontheexpirationforthisextendedreportingperiod.Duringthefirstseveralyearsofaclaims- maderelationship,claims-maderatesarecomparativelylowerthanoccurrencerates.Theinsuredcanexpectsubstantialannualpremium increasesindependentoverallrateincreasesuntiltheclaims-maderelationshiphasmatured.
VirginiaNotice:ThisPolicyiswrittenonaclaims-madebasis.Pleasereadthepolicycarefullytounderstandyourcoverage.Youhave
anoptiontopurchaseaseparatelimitofliabilityfortheextendedreportingperiod.Ifyoudonotelectthisoption,thelimitofliabilityforthe extendedreportingperiodshallbepartoftheandnotinadditiontolimitspecifiedinthedeclarations.Ifyouhaveanyquestionsregardingthe costofanextendedreportingperiod,pleasecontactyourinsurancecompanyoryourinsuranceagent.Statementsintheapplicationshallbe deemedtheinsured’srepresentations.Astatementmadeintheapplicationorinanyaffidavitmadebeforeorafteralossunderthepolicywill notbedeemedmaterialorinvalidatecoverageunlessitisclearlyproventhatsuchstatementwasmaterialtotheriskwhenassumedandwas untrue.
ColoradoFraudStatement: Itisunlawfultoknowinglyprovidefalse,incomplete,ormisleadingfactsorinformationtoaninsurancecompany forthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsurance,andcivil damages.Anyinsurancecompanyoragentofaninsurancecompanywhoknowinglyprovidesfalse,incomplete,ormisleadingfactsor informationtoapolicyholderorclaimantforthepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimantwithregardtoa settlementorawardpayablefrominsuranceproceedsshallbereportedtotheColoradodivisionofinsurancewithinthedepartmentof regulatoryagencies.
DistrictofColumbiaFraudStatement: WARNING:Itisacrimetoprovidefalseormisleadinginformationtoaninsurerforthepurposeof defraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/orfines.Inaddition,aninsurermaydenyinsurancebenefitsif falseinformationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
FloridaFraudStatement: ThefollowingstatementappliesifyoupurchaseapolicywithMountVernonFireInsuranceCompanywhichisour surpluslinescarrierinFlorida.Youmayreviewyourquoteorcontactyouragentorbrokertoverifyifyourcoverageiswiththesurpluslines carrier.Youareagreeingtoplacecoverageinthesurpluslinesmarket.Superiorcoveragemaybeavailableintheadmittedmarketandata lessercost.PersonsinsuredbysurpluslinescarriersarenotprotectedundertheFloridaInsuranceGuarantyActwithrespecttoanyrightof recoveryfortheobligationofaninsolventunlicensedinsurer.
KentuckyFraudStatement: Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplication forinsurancecontaininganymateriallyfalseinformationorconceals,forthepurposeofmisleading,informationconcerninganyfactmaterial theretocommitsafraudulentinsuranceact,whichisacrime.
MaineandWashingtonFraudStatement: Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurance companyforthepurposeofdefraudingthecompany.Penaltiesmayincludeimprisonment,finesoradenialofinsurancebenefits.
NewJerseyFraudStatement: Anypersonwhoincludesanyfalseormisleadinginformationonanapplicationforaninsurancepolicyis subjecttocriminalandcivilpenalties.
NewYorkFraudStatement: Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplication forinsuranceorstatementofclaimcontaininganymateriallyfalseinformation,orconcealsforthepurposeofmisleading,information
concerninganyfactmaterialthereto,commitsafraudulentinsuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynotto exceedfivethousanddollarsandthestatedvalueoftheclaimforeachsuchviolation.
OhioFraudStatement: Anypersonwho,withintenttodefraudorknowingthatheisfacilitatingafraudagainstaninsurer,submitsan applicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
OklahomaFraudStatement: WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesany claimfortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
PennsylvaniaFraudStatement: Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesan applicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconcealsforthepurposeofmisleading,information concerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivil penalties.
TennesseeandVirginiaFraudStatement:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurance companyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
VermontFraudStatement:Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowingly presentsfalseinformationinanapplicationforinsurancemaybesubjecttofinesandconfinementinprison.
FraudStatement(AllOtherStates): Anypersonwhoknowinglypresentsafalseorfraudulentclaimfor paymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguilty ofacrimeandmaybesubjecttofinesandconfinementinprison.
IfyourstaterequiresthatwehaveinformationregardingyourAuthorizedRetailAgentorBroker,pleaseprovidebelow.
Retailagencyname: / License#:
Agencymailingaddress:
City: / State: / Zipcode:
Mainagencyphonenumber:
ThesignerofthisapplicationacknowledgesandunderstandsthattheinformationprovidedinthisApplicationismaterialtotheInsurer’s decisiontoprovidetherequestedinsuranceandisreliedonbytheInsurerinprovidingsuchinsurance.Thesignerofthisapplication representsthattheinformationprovidedinthisApplicationistrueandcorrectinallmatters.ThesignerofthisApplicationfurtherrepresents thatanychangesinmattersinquiredaboutinthisApplicationoccurringpriortotheeffectivedateofcoverage,whichrendertheinformation providedhereinuntrue,incorrectorinaccurateinanywaywillbereportedtotheInsurerimmediatelyinwriting.TheInsurerreservesthe righttomodifyorwithdrawanyquoteorbinderissuedifsuchchangesarematerialtotheinsurabilityorpremiumcharged,basedonthe Insurer’sunderwritingguides. TheInsurerisherebyauthorized,butnotrequired,tomakeanyinvestigationandinquiryinconnectionwith theinformation,statementsanddisclosuresprovidedinthisApplication.ThedecisionoftheInsurernottomakeortolimitanyinvestigation orinquiryshallnotbedeemedawaiverofanyrightsbytheInsurerandshallnotestoptheInsurerfromrelyingonanystatementinthis
ApplicationintheeventthePolicyisissued.ItisagreedthatthisApplicationshallbethebasisofthecontractshouldapolicybeissuedandit willbeattachedandbecomeapartofthePolicy.
Applicant’ssignature: / Title: / Date:
Principal,Partner,orOfficeroftheFirm

Please send completed application to , and / or

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