ADMIRAL INSURANCE COMPANY



ADMIRAL INSURANCE COMPANY

6455 East Johns Crossing, Suite 240

Duluth, GA 30097

Phone: 770-476-1561 - Fax: 770-418-9597

Internet:

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REAL ESTATE SERVICES

PROFESSIONAL LIABILITY

APPLICATION

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NOTE: COMPLETION AND SUBMISSION OF THIS APPLICATION IS FOR THE PURPOSE OF SECURING A PREMIUM QUOTATION ONLY. NO COVERAGE WILL BE AFFECTED UNTIL RECEIPT OF WRITTEN INSTRUCTION AND PREMIUM PAYMENT. ANY SUBSEQUENT CONTRACT ISSUED WILL BE IN FULL RELIANCE UPON THE STATEMENTS AND REPRESENATIONS MADE IN THIS APPLICATION (AND ATTACHMENTS HERETO) AND THIS APPLICATION WILL BE MADE A PART OF THE POLICY.

IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS. THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR DEFENSE EXPENSES. AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE APPLICATION DEDUCTIBLE AMOUNT.

All questions must be fully completed. If there is insufficient space to complete an answer, continue on a separate sheet of the Applicant’s letterhead. If a question is not applicable, state “N.A.” This form must be completed, signed and dated by a Principal of the Applicant.

SECTION I ( GENERAL INFORMATION

1. Full name of Applicant (include All firm names, trade names or dba’s under which the applicant operates, including subsidiaries): ___________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________

2. Address of Principal Office: _______________________________________________________________________

(street) (city/state) (zip)

3. List all states in which Applicant operates: ____________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________

4. Does the Applicant have any other locations? If yes, list complete addresses on a separate. ___Yes ___No

5. Date Established: __________/__________/__________ Website Address: ______________________________

6. Applicant is a: ____Sole Proprietor ____Corporation

____Partnership ____Joint Venture

____Independent Contractor ____Other: (specify): ____________________________

7. Effective date desired: __________/__________/__________

8. Date first licensed as: Agent__________ Broker___________

9. Limits of Liability desired (inclusive of defense expenses): ______________Per Claim ______________Aggregate

Deductible desired (inclusive of defense expenses): ______________Per Claim ______________Aggregate

10. Has the name of the Applicant ever changed or has there been any acquisition, consolidation, dissolution, merger or any other change in business organization during the past (5 ) years? ___Yes ___No. If yes, please provide full particulars on a separate sheet, including all Firm names, in chronological order. Additionally, provide claims information (as per SECTION XII) for all prior Firms.

11. During the coming twelve (12) months, does the Applicant contemplate offering any services not currently offered, or any mergers or acquisitions? ___Yes ___No. If yes, please explain on separate attachment to this application.

12. Indicate Staffing:

Independent Number

Employees Contractors Licensed

A. Principals, Partners, Officers, Directors _________ _________ _________

B. Real Estate Sales Agents/Brokers _________ _________ _________

C. Property Managers _________ _________ _________

D. Real Estate Leasing Agents/Brokers _________ _________ _________

E. Notaries _________ _________ _________

F. Mortgage Brokers _________ _________ _________

G. Construction Managers (Owner’s Representatives) _________ _________ _________

H. Title Agents _________ _________ _________

I Escrow Agents _________ _________ _________

J. Real Estate Developers _________ _________ _________

K. Real Estate Asset Managers/Investment Advisors _________ _________ _________

L. Clerical _________ _________ _________

M. Other: (specify): __________________________________ _________ _________ _________

________________________________________________

TOTAL STAFF: _________ _________ _________

13. Average value of property sold ______________

Largest value of property sold ______________

14. Complete the following for each partner, principal, officer and director of the Applicant (DESIGNATION CODES: P=Partner, PR=Principal, O=Officer, D=Director)

| | |Date of |Professional | |

| | |Affiliation |Designations |Association |

|Name |Designation |with Applicant |Received |Memberships |

| | | | | |

|__________________________________________________|______________________|_______________________|_______________________|__________________________________|

|__________________________________________________|______________________|_______________________|_______________________|__________________________________|

|_____________________________________________ |___________ |______________ |______________ |___________________________ |

15. Specify gross income derived from the following services: Current Estimated

A. Residential Real Estate Sale Commissions $___________ $___________

B. Non-Residential Real Estate Sales Commissions $___________ $___________

C. Property Management Fees $___________ $___________

D. Real Estate Leasing Commissions/Fees $___________ $___________

E. Mortgage Brokerage Fees $___________ $___________

F. Real Estate Appraisal $___________ $___________

G. Real Estate Asset Management/Investment Advisory Commissions/Fees*$___________ $___________

H. Title & Escrow Commissions/Fees $___________ $___________

I. Insurance Brokerage Commissions/Fees (excluding title insurance) $___________ $___________

J. Property Development Fees $___________ $___________

K. Construction Management Fees $___________ $___________

L. Other (specify): _____________________________________________ $___________ $___________

TOTALS $___________ $___________

(* Inclusive of information, promotion, syndication, offer or sale of general or limited partnership interest, Real Estate Investment Trusts, or any investments regulated by the SEC or NASD.)

16. Does the applicant represent buyer ________% seller ________%

GENERAL PROCEDURES AND CLAIMS HISTORY

17. Does the Applicant have an in-house legal department? ___ Yes ___ No. If yes, briefly describe nature of legal services rendered by in-house counsel: ____________________________________________________________________________________________________________________________________________________________________________________________

18. List firm name, contact person and address of outside legal counsel:

____________________________________________________________________________________________________________________________________________________________________________________________

19. List firm name, contact person and address of outside CPA/accounting firm:

____________________________________________________________________________________________________________________________________________________________________________________________

20. Has any claim ever been made against the firm? ___ Yes ___ No.

If yes, please attach details stating:

1. date when claim was made 5. nature of the claim

2. date the act giving rise to the claim was committed 6. amount of alleged damages

3. name of the claimant 7. amount of reserves if claim is open

4. final disposition (include paid indemnity amounts and expense amounts)

21. After inquiry, is the Applicant, any predecessors in business or any other person for whom coverage is requested aware of any act, error, omission or circumstance which may possibly result in a claim being made against them?

___ Yes ___ No. If yes, attach a statement giving full details.

22. Has the Applicant, any predecessors in business or any other person for whom coverage is requested ever reported a potential claim circumstance to a professional liability carrier? ___ Yes ___ No. If yes, attach a statement giving full details.

I/we hereby declare that the above statements and representations are true and that i/we have not suppressed or misstated any material facts and I/we agree that this application shall be basis of any subsequent contract of insurance with the company. Signature of the application does not bind the applicant or the company to complete the insurance and the company retains the right to determine the minimum acceptable limit of liability.

___________________________ ________________________________________________________

Date Signature of Applicant Title

|ADMIRAL INSURANCE COMPANY | |

|6455 East Johns Crossing, Suite 240 |SUPPLEMENTAL FOR |

|Duluth, GA 30097 |REAL ESTATE SERVICES |

|Phone: 770-476-1561 ( Fax: 770-418-9597 |PROPERTY MANAGEMENT SERVICES |

|Internet: | |

1. List top five (5) properties managed, type of property (e.g., residential, office, commercial, retail, industrial, farm, vacant land) most recently appraised value, amount of Applicant’s ownership/equity interest therein:

|Location |Types of |Appraised |Ownership/ |

|Address |Property |Value |Equity Interest % |

|_______________________________ |________________ |______________ |_________________ |

|_______________________________ |________________ |______________ |_________________ |

|_______________________________ |________________ |______________ |_________________ |

|_______________________________ |________________ |______________ |_________________ |

|_______________________________ |________________ |______________ |_________________ |

2. Is a credit report obtained on all respective tenants? ___ Yes ___ No

3. Is a budget prepared for each property managed? ___ Yes ___ No

4. Does the Applicant handle collections? ___ Yes ___ No

5. Does the Applicant maintain responsibility for maintaining insurance coverage

on each property managed? ___ Yes ___ No

Are all managed properties insured to value? ___ Yes ___ No

Specify he minimum Commercial General Liability (“CGL”) coverage limit required on managed properties: ____________________________________________________-----------------------------------_________________________

6. Briefly describe procedures for handling tenant complaints: ____________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Attach a copy of the Applicants standard management contract.

8. Commercial _____%

Residential _____%

9. Average value of property managed $ __________________

Largest value of property managed $ __________________

10. Are any properties managed

Time Shares ____Yes ____No

Vacation Property ____Yes ____No

Condominiums ____Yes ____No

I understand that the information submitted herein becomes a part of my Real Estate Services Errors & Omissions Application and is subject to the same representation and conditions.

______________________________ ________________________________________________________________________

Date Signature of Applicant Title

|ADMIRAL INSURANCE COMPANY | |

|6455 East Johns Crossing, Suite 240 |SUPPLEMENTAL FOR |

|Duluth, GA 30097 |REAL ESTATE SERVICES |

|Phone: 770-476-1561 ( Fax: 770-418-9597 |REAL ESTATE APPRAISAL SERVICES |

|Internet: | |

1. Provide the following information for the most recent 12 months:

| | | |Highest Value |

| |Number of Appraisals |Fee Income |Past 12 Months |

|Residential |_____________________ |_____________________ |_____________________ |

|Commercial |_____________________ |_____________________ |_____________________ |

|Other: ___________ |_____________________ |_____________________ |_____________________ |

2. Describe to appraisal clients (e.g., banks, individuals, investors, and other): ___________)___________________

______________________________________________________________________________________________________________________________________________________________________________

3. Attach a copy of the Applicants standard property appraisal contract.

I understand that the information submitted herein becomes a part of my Real Estate Services Errors & Omissions Application and is subject to the same representation and conditions.

______________________________ _________________________________________________________________

Date Signature of Applicant Title

|ADMIRAL INSURANCE COMPANY | |

|6455 East Johns Crossing, Suite 240 |SUPPLEMENTAL FOR |

|Duluth, GA 30097 |MORTGAGE BROKERS |

|Phone: 770-476-1561 ( Fax: 770-418-9597 | |

|Internet: | |

This is a supplemental application to be completed with the Miscellaneous Professional Liability Insurance Application.

Applicant’s Name________________________________________________________________________________

If the Applicant is newly established, please provide best estimates.

1. Indicate the percentage of Gross Revenues from the following activities:

a. Loan Origination ______________________%

b. Loan Servicing ______________________%

c. Loan Underwriting ______________________%

d. Loan Funding/Lending ______________________%

e. Yield Spread Premiums ______________________%

f. Other __________________________ ______________________%

Total 100 %

2. Indicate the percentage for each mortgage type:

a. Residential ______________________%

b. Commercial ______________________%

c. Residential Construction ______________________%

d. Commercial Construction ______________________%

e. Other Construction ______________________%

f. Other __________________________ ______________________%

Total 100%

3. Do you anticipate doing any subprime loans (credit score 620 or lower) within the next 12 months? θ Yes θ No

4. What percentage of your gross revenue will come from subprime loans? _____________________%

5. If you indicated zero percentage in Question 4 above, please advise the following:

a. Have you ever provided a subprime market loan? θ Yes θ No

b. When was the date of the last subprime loan provided: ____ / ____/ ____

c. Why did you stop providing subprime loans?_____________________________________________________

_________________________________________________________________________________________

d. Did your prior professional liability insurance (if applicable) exclude subprime loans? θ Yes θ No

6. What percentage of your Gross Revenues is derived from reverse mortgages?________________%

7. What percentage of your Gross Revenues is derived from Federal Housing Authority (FHA) and Veteran’s Administration (VA) loans? ______________________%

8. What percentage of your Gross Revenues is derived from interest-only loans? ______________________%

9. Does the Applicant have an in-house line of credit? θ Yes θ No

10. Are you affiliated with, or do you have common ownership with a real estate development company or real estate agency for which you provide mortgage loan services? θ Yes θ No If yes, provide details: ___________________________________

____________________________________________________________________________________________________

11. Are you affiliated with, or do you have common ownership with a financial lending institution? θ Yes θ No If yes, provide details._______________________________________________________________________________________________

12. Do you provide origination services on behalf of only one bank or lender? θ Yes θ No If yes, provide details:___________

____________________________________________________________________________________________________

13. For the past 12 months, what was your:

a. Average Loan Size $________________________

b. Largest Loan Originated $________________________

c. Total Dollar Value of Loans Originated $________________________

14. Have you, or any past or present staff member ever been criticized, disciplined, or fined by any governmental agency, regulatory entity, investor group, warehouse wholesaler/banker, or the Department of Housing and Urban Development (HUD)? θ Yes θ No If yes, provide details: _______________________________________________________________

____________________________________________________________________________________________________

15. Have you ever closed a loan with a lender that went into bankruptcy or is no longer in business? θ Yes θ No

If yes, provide the following information:

Name of Defunct Lender # of Loans $ Value of Loans

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

This Mortgage Brokers Supplemental Application is attached to and forms part of the Professional Liability Application. This supplemental application is subject to the same provisions concerning representations made in the basic application.

_____________________________________________________________________ ______________________ Signature Title Date

_____________________________________________________________________

Print Name

|ADMIRAL INSURANCE COMPANY | |

|6455 East Johns Crossing, Suite 240 |SUPPLEMENTAL FOR |

|Duluth, GA 30097 |REAL ESTATE SERVICES |

|Phone: 770-476-1561 ( Fax: 770-418-9597 |TITLE & ESCROW SERVICES |

|Internet: | |

1. List states where the Applicant provides title and/or escrow services: _______________________________________ ______________________________________________________________________________________________

2. Does the Applicant provide U.C.C. reports? ___ Yes ___ No

Are such reports certified by the Applicant for accuracy? ___ Yes ___ No

3. List title insurance companies represented by the Applicant: _____________________________________________

______________________________________________________________________________________________

(Attach complete copies of Agency Agreements/Contracts between the Applicant and the companies listed above.)

4. Who performs title searches for title insurance policies issued by the Applicant? ______________________________ ______________________________________________________________________________________________

5. List percentages of data compiled from the following sources (must equal 100%):

_____ Courthouse Records _____ Computer/Databases (using in-house programs)

_____ Independent Abstractors/Searches _____ Non-Owned or Shared Computers/Databases

_____ Title Insurance Company Plant (specify): ____________________________________________

6. Does the Applicant render title opinions? ___ Yes ___ No

7. Provide a percentage breakdown of title commissions/fees attributable to the following categories of real estate:

_____ Residential _____ Commercial _____ Agricultural

_____ Industrial _____ Oil & Gas _____ Minerals

_____ Other (specify): ____________________________________________________________________

8. Describe procedures for ensuring that commingling of escrow funds does not occur: __________________________

____________________________________________________________________________________________________________________________________________________________________________________________

9. Does the Applicant maintain a fidelity bond? ___ Yes ___ No. If yes, please specify name of carrier, limits and effective/expiration dates: ______________________________________________________________

_______________________________________________________________________________________

I understand that the information submitted herein becomes a part of my Real Estate Services Errors & Omissions Application and is subject to the same representation and conditions.

______________________________ ________________________________________________________________

Date Signature of Applicant Title

|ADMIRAL INSURANCE COMPANY | |

|6455 East Johns Crossing, Suite 240 |SUPPLEMENTAL FOR |

|Duluth, GA 30097 |REAL ESTATE SERVICES |

|Phone: 770-476-1561 ( Fax: 770-418-9597 |REAL ESTATE LEASING SERVICES |

|Internet: | |

1. Indicate total amount of financing handled b the Applicant during the past twelve (12) months. $ _________

| |Residential |Commercial |Other |

|A. Amount of Principal |$________________ |$_____________ |$______________ |

|B. Number of leases |_________________ |______________ |_______________ |

|C. Maximum value of any single lease |$________________ |$_____________ |$______________ |

2. Does the Applicant handle assets other than real estate (e.g., heavy machinery, high-tech equipment, office equipment, and automobiles)? ___ Yes ___ No. If yes, briefly describe: ____________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________

3. Indicate percentage of: _____% Operating leases _____% Capital Leases

4. Have any leasing structures arranged by the Applicant ever been dismissed by the IRS? ___ Yes ___ No. If yes, provide details: _________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Does the Applicant have discretionary authority to commit other’s funds? ___ Yes ___ No. If yes, provide details: ______________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Types of Residential Properties Leased: Apartments ___________

Condominiums ___________

Single Family Homes ___________

I understand that the information submitted herein becomes a part of my Real Estate Services Errors & Omissions Application and is subject to the same representation and conditions.

______________________________ ______________________________________________________________

Date Signature of Applicant Title

|ADMIRAL INSURANCE COMPANY | |

|6455 East Johns Crossing, Suite 240 |SUPPLEMENTAL FOR |

|Duluth, GA 30097 |REAL ESTATE SERVICES |

|Phone: 770-476-1561 ( Fax: 770-418-9597 |REAL ESTATE SALES & BROKERAGE SERVICES |

|Internet: | |

1. List Board of Realtors memberships: ________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________

2. Does the Applicant participate in multiple listing services? ___ Yes ___ No

3. Is the Applicant a member or affiliate of any national franchise, referral or relocation organization?

___ Yes ___ No. If yes, please list membership(s)/affiliation(s): __________________________________ ______________________________________________________________________________________________________________________________________________________________________________

4. With respect to residential sales, does the applicant use standard contract forms approved by a local Board of Realtors or State Association of Realtors? ___ Yes ___ No.

5. Does the Applicant participate in any home protection or warranty programs? ___ Yes ___ No. If yes, indicate percentage of properties sold during the past twelve (12) months which were covered under such program(s) and briefly describe the program(s): ________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________

6. Specify number of transactions by category for the past twelve (12) months:

_____ Residential (1-4 Family) _____ Commercial _____ Industrial/Warehouse

_____ Multi-family _____ Office Building _____ Hotel/Motel

_____ Condos/Co-ops _____ Retail/Shopping _____ Vacant Land/Agricultural

_____ Other (specify): ___________________________________________________________________

7. List top three (3) transactions, by property value, for past twelve (12) months:

|Description of Property Location |Value |Commission/Fee Income |

|A. _________________________________ |$______________________ |$______________________ |

|B. _________________________________ |$______________________ |$______________________ |

|C. _________________________________ |$______________________ |$______________________ |

8. During the past twelve (12) months, has the Applicant purchased or sold any properties in which the Applicant has held a direct/indirect beneficial ownership interest? ___ Yes ___ No. If yes, please attach complete details including description and location of property, market value and percentage of equity interest.

I understand that the information submitted herein becomes a part of my Real Estate Services Errors & Omissions Application and is subject to the same representation and conditions.

______________________________ _______________________________________________________________

Date Signature of Applicant Title

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