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To be eligible for this application you must be able to answer “True” to statements 1-6 below. Please note that mortgage brokering coverage is not offered with the Express Application.
Please contact our office if you are not eligible for this program or need mortgage brokering coverage.
Applicant Company Name
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Name of Principal Broker
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| Address |
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| Mailing Address (if different) |
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| In lieu of mailing my policy, you may email my policy to the above address. I agree to receive an electronic copy of my application with my policy. |
Total # of professionals earning $20,000/yr or more
Total # of professionals earning less than $20,000/yr
Annual # of Transaction Sides
(on closed real estate sales)
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| NEW BUSINESS ACCOUNTS:
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| RENEWAL ACCOUNTS:
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To be eligible for the premium options shown below, the Responses to statements 1 through 6 must all be “True”.
- No owner, agent or member of the applicant company has had their license revoked, been investigated or been subject to any disciplinary action by any
licensing board, real estate association or other regulatory body within the last 5 years.
- No owner, agent or member of applicant company has been cancelled, refused insurance or declined by another Carrier during the
last 5 years (except due to loss of market or non payment of premium).
- No owner, agent or member of the company is involved in property management, development or construction.
- No owner or agent of the company is an exclusive agent for a builder or developer.
- The applicant’s total gross revenues did not exceed $ 300,000.00 for the last three (3) year period. (gross revenues are
defined as all fees and commissions before expenses payable to employees and independent contractors).
- The applicant and anyone to whom this insurance will apply is not aware of any professional liability claim or any acts, errors, omissions
or Personal Injuries which might reasonably be expected to be the basis of a claim made against them within the past 5 years.
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PLEASE SELECT YOUR DESIRED PREMIUM OPTION
If you have a policy in force, you will need prior acts coverage. Fax (805) 495-2494 or email jsmigiel@stevereichinsurance.com a copy of your current Declarations page showing the prior acts date. |
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CALIFORNIA
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Deductible Loss &
Expense |
$100,000/$300,000 |
$250,000/$250,000 |
$500,000/$500,000 |
$500,000/$1,000,000 |
$1,000,000/$1,000,000 |
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$1,000 |
$951 |
$1,012 |
$1,121 |
$1,180 |
$1,265 |
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$2,500 |
$865 |
$920 |
$1,019 |
$ 1,073 |
$1,150 |
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$5,000 |
$821 |
$873 |
$968 |
$ 1,019 |
$ 1,093 |
Claim Expenses are Outside the Limits of Liability
California Residents must include A Surplus Lines State Tax and Stamping Fee (3% State Tax and Stamping Fee).
If your effective date is before 02/01/2010 the stamping fee is 0.225%. Otherwise the
stamping fee is 0.25%. Please add this to the premium selected.
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DISCLAIMER
For California Residents: General Star Indemnity Company is a “non-admitted” or “surplus lines” insurer in California and is not subject to the financial solvency regulation and enforcement, which applies to licensed companies. The Insurance company does not participate in any state insurance guarantee fund; therefore, these funds will not pay your claims or protect your assets if the insurance company becomes insolvent and is unable to make payments as promised. Your agent or broker can verify with the State Insurance Commissioner that General Star Indemnity Company is an approved surplus lines insurer in the state. California Surplus lines license # OB11941, Herbert H. Landy Insurance Agency Inc., Needham, MA 02494.
FRAUD WARNING
Any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any material false information or conceals for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties and denial of insurance benefits.
REQUIRED SIGNATURE
IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT. SHOULD A POLICY BE ISSUED IT WILL ATTACH TO THE POLICY.
I understand that the final premium will be rounded to the next dollar. I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my Professional Liability application.
I agree
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