MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE

REAL ESTATE OPERATIONS SUPPLEMENT

1. Name of the Applicant’s firm:

2. Please complete the appropriate sections stating the annual gross commissions and/or fees earned by the Applicant during the last twelve months from:

	REVENUE	NUMBER OF TRANSACTIONS
a. Real Estate Sales/Brokerage	$
b. Real Estate Property Management Types of Properties Managed:	$
c. Commercial Space Leasing	$
d. Real Estate Appraisals	$
e. Mortgage Brokerage/Banking	$
f. Real Estate Consulting Describe type of consulting:	$
g. Syndication/Partnerships (please provide sample offerings, agreements, descriptions of activities by emailing Gross Insurance and attaching the documents containing the information needed.)	$
h. Property Development and/or Construction	$
i. Business Opportunities Brokerage	$
TOTAL	$

3. Indicate the percentage of the Applicant’s total income derived from the following:

Commercial % Agricultural %

Residential % Undeveloped Land %

Industrial % Other %

4. Please give a breakdown of the Applicant’s sales personnel between employees and independent contractors:

(please enclose a sample contract used with Independent Contractors by emailing Gross Insurance and attaching the contract.)

# of Employees:

# of Independent Contractors:

5. If the Applicant manages properties of others, please forward a representative contract and answer the following:

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

If no, why not?

b. Does the Applicant obtain credit reports on prospective tenants? Yes No

If yes, describe procedure.

c. Is the Applicant responsible for negotiating, effecting or maintaining insurance coverage on properties managed? Yes No

If yes, describe the extent of the Applicant’s involvement or services in this area.

6. Does the Applicant or any of the Applicant’s direct relatives or affiliated/subsidiary entities, have any ownership or equity interest in any property being managed or held for sale? Yes No

If yes, please provide a schedule of such properties and describe the Applicant’s interest.

Also, advise total revenues received from such properties annually:

7. Please complete the following if the Applicant performs property appraisals:

(Please relate answer to Item 2.d. above.)

a. What percentage of the Applicant’s total estimated commissions/fees for the next year does the Applicant anticipate to be derived from appraisals for:

Private Individuals: % Attorneys: %

Banks: % Municipalities: %

Insurance Companies: % Other: %

b. What is the estimated number of appraisals the Applicant will perform during the next year for the following type of properties/projects? (If none are anticipated, please indicate so.)

1-4 Family Residences Industrial Facilities

Multi-Family Residences Agricultural Properties

Undeveloped/Vacant Land Property Syndication

Shopping Centers/Malls Development Projects

Office Building Portfolio Valuations

Other Commercial Properties

8. Are there any other companies who own any percentage of the Applicant’s company, does the Applicant own any percentage ofany other company or is the Applicant in any other way affiliated with any other company? Yes No

a. If yes, advise who they are and explain the nature and extent of the relationship(s).

b. For which of these does the Applicant wish to extend coverage?

9. Does the Applicant have any written or oral agreements or understandings with any other company that involves the referral of business to or from the Applicant’s company? Yes No

a. If yes, advise who they are and explain the nature and extent of the agreements or understandings.

b. If yes, advise if and how any compensation is exchanged under the agreements or understandings.

c. If yes, advise whether the relationships between the companies are disclosed to the individuals involved in the transactions involving these referrals.

d. Please indicate if any such written agreements and/or any such disclosures have been reviewed by an attorney.

10. Is the Applicant a party to an “affiliated business arrangement” as defined by the Real Estate Settlement Procedures Act?
Yes No

THE REAL ESTATE SETTLEMENT PROCEDURES ACT DEFINES "AFFILIATED BUSINESS ARRANGEMENT" AS AN "ARRANGEMENT IN WHICH (A) A PERSON WHO IS IN A POSITION TO REFER BUSINESS INCIDENT TO OR A PART OF A REAL ESTATE SETTLEMENT SERVICE INVOLVING A FEDERALLY RELATED MORTGAGE LOAN, OR AN ASSOCIATE OF SUCH PERSON, HAS EITHER AN AFFILIATE RELATIONSHIP WITH OR A DIRECT OR BENEFICIAL OWNERSHIP INTEREST OF MORE THAN ONE PERCENT IN A PROVIDER OF SETTLEMENT SERVICES; AND (B) EITHER OF SUCH PERSONS DIRECTLY OR INDIRECTLY REFERS SUCH BUSINESS TO THAT PROVIDER OR AFFIRMATIVELY INFLUENCES THE SELECTION OF THAT PROVIDER."

a. If yes, advise who the parties to the arrangement are, and describe the nature of the arrangement.

b. If yes, advise whether “Affiliated Business Arrangement Disclosure Statements” are provided to the persons being referred.
Yes No
If yes, please provide a copy of such disclosure by emailing Gross Insurance and attaching the document.

c. If yes, advise whether the persons being referred are required to use any particular provider of real estate settlement services.

d. If yes, advise what money or other thing of value is exchanged under the affiliated business arrangement.

THIS REAL ESTATE OPERATIONS SUPPLEMENT IS ATTACHED TO AND FORMS A PART OF THE MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE POLICY APPLICATION. IT IS SUBJECT TO THE SAME PROVISIONS CONCERNING REPRESENTATIONS MADE AS IN THE BASIC APPLICATION.

Date Signature/Title

NOTE: THE SIGNATURE MUST BE THAT OF AN ACTIVE OWNER, PARTNER OR EXECUTIVE OFFICER OF THE APPLICANT’S FIRM.

MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE - REAL ESTATE OPERATIONS SUPPLEMENT<