EmailMeForm
Name of Firm
*
Phone #
*
Email Address
*
Name of Contact
Website Address
Address
Street Address
City
State / Province / Region
Postal / Zip Code
Is the applicant a member of the National Association of REALTORS®?
Yes
No
Is the applicant part of a real estate franchise?
Yes
No
If Yes what Franchise?
Is the applicant's firm a
Please select
Sole Propertiorship
Partnership
Corporation
LLC
Independent Contractor
Has the applicant been licensed as a real estate broker for less than 3 years?
Yes
No
Have any claims been made against the applicant or a member of their staff within the past 6 years? Include violation of fair housing laws or licensing board complaints.
Yes
No
Is the applicant aware of any act, error, omission or other circumstance they expect to be the basis of claim or suit against them or their staff within the past 6 years?
Yes
No
Has the applicant's license ever been revoked/suspended?
Yes
No
How many years has the applicant held a license as an agent?
How many years has the applicant held a license as a broker?
Does the applicant hold any other professional licenses?
Yes
No
Staff Information (Count each individual only once)
Principals, partners, directors and officers
Real estate agents, brokers, independent contractors
Number of Full Time
Number of Part Time
Property Managers
Number of Full Time
Number of Part Time
Appraisers
Number of Full Time
Number of Part Time
Referral agents (referring only to applicant)
Number of Full Time
Number of Part Time
Clerical/ administrative
Number of Full Time
Number of Part Time
Total number of employees (excluding principals, partners, directors, officers and other staff)
Number of Full Time
Number of Part Time
Is the applicant involved in any of the services listed below?
Yes
No
Please Check if Yes
Environmentally impacted sites
Property preservation
1031 exchanges
Real estate development
Construction management
Sale of timeshares
Appraisal management
Title/ abstract/ escrow
Hotels, motels, mobile home/ rv parks
Mortgage banking (other than origination)
Formation or management of group investments, syndications, trusts and/or partnerships
Business valuations
Total percentage revenue to the applicant:
Is the applicant involved in any of the services listed below?
Yes
No
Please Check if Yes
Does the applicant construct or develop properties they own?
Does the applicant own more than 25% of property that they lease?
Does the applicant own more than 25% of property that they sell?
Does the applicant own more than 25% of property that they manage?
Does the applicant derive more than 25% of its total revenues from a single client?
Does the applicant maintain an exclusive listing agreement with a builder or developer?
Provide the applicant's total gross income, including fees and commissions, before any splits or deductions for the past fiscal year. If the applicant is a startup, provide a 12 month estimate.
Fiscal Year
Residential Brokerage (1-4 units):
Number of Transactions
Income
Commercial, Industrial, Income Property Sales
Number of Transactions
Income
Land and Lot Sales
Number of Transactions
Income
Farm, Agriculture, Vineyard and/or Forestry
Number of Transactions
Income
Residential Real Estate Appraisal
Number of Transactions
Income
Commercial Real Estate Appraisal
Number of Transactions
Income
Real Estate Leasing Fees
Number of Transactions
Income
Residential Property Management Fees (1-4 units)
Number of Transactions
Income
Commercial or Habitational (5+ units) Property Management Fees
Number of Transactions
Income
Management of Associations (i.e. condos, coops, homeowners)
Number of Transactions
Income
Mortgage Brokerage
Number of Transactions
Income
Business Opportunities Brokerage
Number of Transactions
Income
Real Estate Consutling/Counseling
Number of Transactions
Income
Auctioneering (Real Property Only)
Number of Transactions
Income
Broker Price Options (BPOs)
Number of Transactions
Income
Residential Brokerage
During the last 12 months:
What was the average sale price of residential properties sold by the applicant?
What percentage of residential properties sold included a home protection or warranty program?
What percentage of residential properties sold included a signed property disclosure form?
In what percentage of transactions did the applicant represent both the buyer and the seller?
In what percentage of transactions did the same agent represent both the buyer and the seller?
What percentage of residential properties sold were foreclosure or short sales transactions?
Does the applicant have an in-house policies/ procedures manual in place?
Yes
No
Does the applicant use local board, state association or other association approved contracts and forms?
Yes
No
In the past 12 months, did at least 75% of the applicant's staff, including independent contractors take approved National Association of REALTORS®, state, or local formal continuing education courses designed to reduce real estate errors & omissions risk?
Yes
No
Does the applicant currently have real estate errors & omissions insurance?
Yes
No
Does the applicant have full retroactive coverage?
Yes
No
Current Policy Info
Policy Period Effective Date
How Long With Current Insurance Carrier
Limit of Liability
Deductible
Annual Premium
