Home Broker Services Corporate Profile Applications Contact Us
PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR REAL ESTATE AGENTS & PROPERTY MANAGERS


NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.



Do not print this page! For blank forms click here. To submit it online, complete this page and select the "Finish" button at the bottom of the page

NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

1. APPLICANT FIRM

1.1 Name

Date Established

Other trade names presently used
1.2 Address

City

Province

Postal Code

Email Address

Phone Number

Fax Number

Website
1.3 If the Applicant Firm has any Branch Offices, please provide their Address(es) (if necessary, please use a separate page and send it to Monarch).
1.4 Name previous organization(s); partnership(s) or other business name(s) (if necessary, please use a separate page and send it to Monarch).
a) Dissolved


Date Dissolved


b) In the course of being dissolved


c) Other
2. PROFESSIONAL PRACTICE

2.1 Give a full description of the Applicant Firm's activities and for each activity show the gross revenues earned during the past 12 months, and the Applicant Firm's forecast for the next 12 months.
a) Principal and all Partners and Directors
DESCRIPTION OF ACTIVITIES GROSS REVENUES
EARNED DURING LAST 12 MONTHS ESTIMATED FOR NEXT 12 MONTHS
Real Estate Sales (Gross Commissions)
Please indicate gross commission percentages in each of the following categories:		 $ $
      - Residential % %
      - Commercial % %
      - Industrial % %
      - Rural (including Farms and Resorts) % %
Market Value Appraisals (on a fee basis) $ $
Property Management (excluding Strata Corporations) $ $
Property Management of Commercial and Residential Strata Corporations $ $
Morgage Brokering $ $
Real Property Leasing Agency $ $
Others (Describe)
 $ $
TOTAL $ $
2.2 Is the Applicant involved in Property Management? If YES, please complete the following:
Yes
No
a) In general, who are your clients?
b) How many properties are currently under the applicant's management?
c) Please provide the total value and a description of the four largest properties presently managed:
1.
2.
3.
4.
d) What is the total value of all properties currently managed?
e) Please describe the nature of the applicant's services, the method used in the management, maintenance and care of the properties as well as the procedures used in buying, maintaining and control of insurance with respect to the managed properties (send a separate page to Monarch if necessary):
f) Does the applicant have a Fidelity Bond in force? If YES, please supply the relevant details:
Yes
No
g) Does the applicant have a Comprehensive General Liability in force? If YES, please supply the relevant details:
Yes
No
2.3 Does the Applicant provide professional services for any firn or company in which the applicant has an ownership interest? If YES, please send the full details to Monarch, also showing the percentage of gross revenues derived therefrom.
Yes
No
2.4 Does the Applicant provide professional services or perform activities outside of Canada? If YES, please describe these services or activites, the location where they are conducted and show the percentage of gross revenues derived therefrom.
Yes
No
2.5 To which Real Estate Association does the applicant belong?
2.6 Applicant's permit number:
2.7 Give a list of all persons performing activities of behalf of the Applicant:
NAME TYPE OF LICENCE HELD ORIGINAL LICENCE DATE NUMBER OF YEARS EXPERIENCE
2.8 Give the total number of all other employees with a breakdown by category (other than those employees listed in question 2.7):
2.9 Has any person shown in question 2.7 ever been object of a dismissal, suspension, or disciplinary sanction? If YES, please append all the relevant details and send to Monarch.
Yes
No
2.10 Does the applicant's gross revenues from any one client exceed50% of the total gross revenues indicated in question 2.2? If YES, please append all the relevant details and send to Monarch.
Yes
No
3. PRIMARY, MANDATORY PRIMARY, OR PRIOR INSURANCE AND CLAIMS:

3.1 Currently or during the last five years, has the Applicant Firm carried Professional Liability (Error and Omissions) Insurance? If YES, please complete the following for all existing and previous insurance.
Yes
No
NAME OF INSURER POLICY NUMBER POLICY PERIOD LIMITS OF LIABILITY DEDUCTIBLE ANNUAL PREMIUM
FROM TO
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
3.2 During the past five years has any Insurer ever cancelled, declined or refused to renew the Applicant Firm's or any previous organization's or partnership's Professional Liability (Errors and Omissions) Insurance? If YES, state in each case, the name of the Insurer and give the reason(s):
Yes
No
INSURER REASONS
3.3 After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, ever been the subject of a claim in respect of the liabilities to be covered by the proposed insurance? If YES, please append full details, the date and amount of the claim(s) on a separate page and send to Monarch.
Yes
No
3.4 After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, ever given notice of a possible claim to an Insurer in respect of the liabilities to be covered by the proposed insurance? If YES, please append full details, the date and amount of the claim(s) on a separate page and send to Monarch.
Yes
No
3.5 After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, is anyone aware of any act or circumstance which could reasonably be expected to be the basis of a future claim in respect of the liabilities to be covered by the proposed insurance? If YES, please append full details, the date and amount of the potential claim(s) on a separate page and send to Monarch.
Yes
No

For the purpose of this Application Form, the word claim, as used in Questions 3.3, 3.4 and 3.5 means:

  1. a verbal or written demand for money damages from a third party;
  2. a verbal or written allegation suggesting that the Applicant Firm or a member of the Applicant Firm including predecessors in business and former staff, may have committed an error, omission or negligent act in respect of professional services provided to a third party; and or
  3. a fact or circumstance arising out of professional services that the Applicant Firm or a member of the Applicant Firm, which could reasonably be foreseen to give rise to a future claim for money damages.

FOR EACH ANSWEROF "YES" TO QUESTIONS 3.3, 3.4 OR 3.5, ON A SEPERATE PAGE, PLEASE PROVIDE THE DATES, CIRCUMSTANCES SURROUNDING THE MATTER CONTEMPLATED BY AN AFFIRMATIVE RESPONSE, TO THOSE QUESTIONS, THE NAMES OF THE CLAIMANT, QUANTUM OF DAMAGES DEMANDED AND THE CURRENT STATUS OF EACH MATTER (CONTINUING, CLOSE, ETC), AND SEND TO MONARCH.
4. COVERAGE AND DEDUCTIBLE (SUBJECT TO THE INSURER'S APPROVAL):

4.1 Limits of liability
$250,000
$500,000
$1,000,000
$2,000,000
Excess of

4.2 Deductible amount each loss:
$1,000
$2,500
$5,000
$10,000
Other
4.3 Suggested effective date of the insurance contract:
REMARKS (optional - or use to complete questions above)
Copyright © Monarch Insurance Brokers Ltd.