1. Name:

Contact:

Address:

Date Established:

; Prior Acts Date:

Phone:

; Fax:

E-mail:

Limits: Select One $250,000/$250,000 $500,000/$500,000 $750,000/$750,000 $500,000/$1,000,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000 $2,000,000/$2,000,000 ; Deductible: Select One $1,000 $2,500 $5,000 $10,000 $25,000

Number Of...

Full Time

Part Time

Inactive

Principals, Partners, Directors, Officers

Licensed Real Estate Agents

Property Management Staff

Real Estate Appraisers

Real Estate Counselors/Consultants

Independent Contractors (I.C.s)

Other Employees (Including Clerical)

Name & Title

Current Status

Year Licensed Agent/Broker

Professional Associations

Professional Designations

7) a. Are you owned or controlled by, or associated with, or do you control or own any other firm or business?

b. Is your firm, or any agent/broker/principal engaged in any business enterprise or profession, OTHER THAN real estate

8. Does rthe applicant have a financial interest in the properties they reprisent?
If YES, please indicte the maximum percentage of ownership for any one property.

9. Does the applicant form or organize group investments, limited partnerships, REITs
or corporations for the purpose of investing in Real Estate?

Yes_or_No Yes No

13. Do you always use local board, state assocaition, or other approved contract forms?
If NO, please send a copy of your forms.

14. In the last 12 Months, what percentage of your agents participated in a formal real-estate related continuing education program designed to reduse broker liability?

15. Real Estate Activities: Show all income, fees and commissions BEFORE split with brokers or deduction of expenses:

Number of
Transactions

Average Transaction Size

Total for Past Fiscal Year

Next 12 Months (estimated)

Residential Real Estate Sales

Farm / Ranch Sales

Commercial, Industrial, Income Property Sales

Property Management Fees (Non Owner)

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Mortgage Broker / Financial Arrangements

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Real Estate Leasing Fees

------

Real Estate Counseling / Consulting

------

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Real Estate Appraisal

------

------

Referral Fees

------

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TOTAL GROSS INCOME:

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PROPERTY MANAGEMENT-Skip to question 23 of question 14 is blank.

16. Property Management Fees for the past fiscal year:

Number of Properties

Total Fees

Single Family Dwelling (not-owned)

Personal Property (not-owned)

Commercial Property (not-owned)

18. Do you have any involvement with real estate activities for which you are a construction manager or property developer?

22. Are you responsible for negotiating, effecting, or maintaining insurance coverage for managed properties?

23. Please complete the following for your firm and any predecessor firms with respect to your Real Estate Agents and Brokers Errors and Omissions Insurance over the past 3 years. If there is no prior coverage write NONE.

Policy Period

Company

Deductible

Limits

Premium or Transaction Rate

CLAIMS- Answer questions 24 and 25 only after consulting each member of your firm.

24. Have you, or anyone indicated in questions 4 or 5, had any claims in the last 10 years?

Select an item Yes No

25. Are you, or anyone indicated in questions 4 or 5, aware of any error, omission or other circumstance which may lead to a claim?

Select an item Yes No

26. During the past 6, years has any Insurance Company declined, canceled or refused to renew for the Applicant or anyone named in response to question 5.

Select an item Yes No

27. Is there any Prior Acts restriction on the Applicant's expiring policy?

Select an item Yes No

28. Have any persons proposed for this coverage ever been subject to disciplinary action by any Real Estate association, state licensing board or other regulatory body as the result of a Real Estate Agent, Broker Property Manager or appraiser activity?

Select an item Yes No

This document is a non-binding indication question sheet and is subject to receipt of a fully completed application and supporting documents prior to firm quotations being rendered by the company.  Upon review of these documents, the company reserves the right to change the terms indicated via this questionnaire or decline to render terms for this coverage.