Real Estate Professionals Liability Insurance - Advance Insurance & Benefits

Real Estate Agent Broker Application

Professional Liability application for Real Estate Professionals. You may Save & Continue this form at any time by clicking the button below. A unique and secure link will be sent to the email you provide so that you can return to the form at a later time.

Step 1 of 5 - Contact Information

Acknowledgment(Required)

I have read and and understand the notice below and warrant the information I am submitting to be true and accurate.

The undersigned, acting on behalf of the Applicant, represents that the statements set forth in this application are true and correct and that thorough efforts were made to obtain requested information from all of You to facilitate the proper and accurate completion of this application.

The undersigned agree that the information provided in this application and any material submitted herewith are the representations of all of You and that they are material and are the basis for issuance of the insurance Policy provided by Us. The undersigned further agree that the application and any material submitted herewith shall be considered attached to and a part of the Policy. Any material submitted with the application shall be maintained on file (either electronically or paper) with Us.
It is further agreed that:

•If any of You discover or become aware of any material change which would render the application inaccurate orincomplete between the date of this application and the Policy inception date, notice of such change will be reportedin writing to Us as soon as practicable;
•Any Policy issued will be in reliance upon the truthfulness of the information provided in this application.
•The signing of this application does not bind the Applicant to purchase insurance.
The information requested in this application is for underwriting purposes only and does not constitute notice to Us under any policy of a Claim or Potential Claim.

GENERAL FRAUD NOTICE: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice: THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THIS POLICY WILL APPLY ONLY TO CLAIMS FIRST MADE AGAINST THE INSUREDS AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD THAT MAY APPLY. PLEASE READ THE POLICY CAREFULLY TO DETERMINE RIGHTS, DUTIES, COVERAGE AND COVERAGE RESTRICTIONS.

RISK PURCHASING GROUP NOTICE
This Miscellaneous Professional Liability Risk Purchasing Group Policy may not be protected by an insurance insolvency guaranty fund in this state, and the insurer or Risk Purchasing Group may not be subject to all the insurance laws and rules of this state.

IMPORTANT NOTICE REGARDING RISK PURCHASING GROUPS Disclosure Pursuant to Federal Law Regarding Purchasing Groups [15 U.S.C. SEC. 3901, et seq] the Norman-Spencer Real Estate Risk Purchasing Group, Inc. is a “Purchasing Group”, as defined under Federal law, formed to purchase liability insurance on a group basis for its Members to cover the similar or related liability exposure(s) to which the Members of the Purchasing Group are exposed by virtue of their related, similar, or common businesses or services. Members do not share limits and each member is provided with its own policy and/or evidence of insurance.