Appraisers Liability Insurance Trust

Transcription

1 Appraisers Liability Insurance Trust Appraisers Liability Insurance Trust Purchasing Group Administered by: LIA Administrators & Insurance Services 1600 Anacapa Street, Santa Barbara, CA P.O. Box 1319, Santa Barbara, CA Tel: (805) (800) Fax: (805) RENEWAL APPLICATION FOR REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY INSURANCE COVERAGE The policy for which this application is made is written on a claims made and reported basis. Coverage is limited to liability for only those claims that are first made against the insured during the policy period and reported to the company in writing no later than sixty (60) days after expiration or termination of the policy for a wrongful act committed on or after the retroactive date and before the end of the policy period. The limits of liability available to pay damages, including judgment or settlement amounts, shall be reduced by amounts incurred for claims expenses. Customer ID: RENEWAL DATE: te: Application must be completed in black ink, and may be submitted by mail, fax or Full Name of Applicant: Include all firm names, trade names or D.B.A.s to be covered: 2. Principal Business Address: City: County: State: Zip: 3. Mailing Address: 4. Branch Address(es): 5. Telephone: Fax: Website: 6. Applicant is: Individual Sole Proprietorship Corporation Partnership LLC/LLP Other 7. List Professional Associations with which the applicant is affiliated: 8. Please complete the following for all persons working for or on behalf of the applicant. If you are applying as an individual or sole proprietor, you must list yourself in this section. Firms must list all principals (active and inactive), employees and independent contractors, regardless of the number of appraisals done. All clerical and support staff should also be listed. Status Codes: P Owner, Principal, Partner T Trainee Appraiser R Realtor ( coverage is applicable A Appraiser O Administrative, Support Staff until selected and bound; see Question 18 for details) te: Clerical and Support staff should be listed, and will be covered at no additional charge. Full Name Status Code Active (A) Inactive (I) Appraisers Certificate or License Number Commercial Currently Held Designations A resume/qualifications sheet must be submitted for all Principals, Appraisers and Trainees listed above. If additional space is required, list on Page 4 (Staff Addendum) or on a separate sheet. Provide a copy of the declarations page(s) for any E&O insurance carried by your independent contractor appraisers. 9. Total number of Appraisers named in Question 8: 10. Total number of clerical / support staff named in Question 8: 11. In the last twelve (12) months, has the name of the applicant changed or has any other business been purchased, merged or consolidated with the applicant? If yes, provide documentation including the date and reason for change, and the names and relationships between all entities involved. Page 1 of 4

2 Customer ID: 12. Complete the following for all residential and commercial appraisals completed, and indicate the percentage (%) of gross annual income derived from each category: A. Residential i. Single-family home or condo Existing Unit ii. Single-family home or condo Undeveloped Lot iii. Multi-family housing (2 to 9 units) Existing Units iv. Multi-family housing (2 to 9 units) Undeveloped Lots v. Other residential properties (describe) % Gross Income Last 12 months Number of s B. Commercial i. Existing multi-family condos or apartments (10 units or more) ii. Existing shopping centers, industrial and office properties iii. Agriculture and/or farm land iv. Vacant land / proposed development a) Condos, apartments or residential projects (10 to 99 units) b) Condos, apartments or residential projects (100+ units) c) All other commercial vacant land / proposed development v. Other commercial properties (describe) C. Total Number of s 100% D. Total Gross Income $ 13. Is the applicant currently providing or planning to provide appraisal management services, including but not limited to managing and / or assigning work to a panel and / or network of contract appraisers? A. If yes, are you seeking coverage for these services? If you answered to Question 13A., a supplemental Management Company application is required. This application is available at: Is applicant currently a staff appraiser for any business entity not named in Question 1? A. If yes, are you seeking coverage for these appraisals? B. If yes, provide the name of the business entity. C. Are all appraisals performed on behalf of the business entity named in 14B included in Question 12? If you answered yes to 14A, salary and appraisal activity must be shown in Question Have any persons named in this application: A. Within the last ten (10) years, been the subject of any disciplinary or corrective action by an appraisal organization, state licensing board or other regulatory body of a governmental entity as a result of their appraisal activities? i. If yes, provide Complaint File Number(s), or if not available, the subject property address(es). B. Been notified of any investigation or review open at this time by any appraisal organization, state licensing board or other regulatory body of a governmental entity? i. If yes, provide Complaint File Number(s), or if not available, the subject property address(es). C. Ever been convicted of a felony, or arrested, indicted, or charged with felonious misconduct? If yes, please provide a written narrative of events. If you answered yes to any section of Question 15, please provide complete documentation and copies of all correspondence, including the Final Order and Stipulation, and/or dismissal if applicable. Page 2 of 4

3 Customer ID: 16. In the last ten (10) years, have any lawsuits or claims (including notice of a potential claim) been made or filed against the applicant, or any person named in this application? This includes lawsuits or claims, regardless if they were tendered to an insurance company for coverage. 17. Is the applicant or any person named in this application aware of any circumstances that may lead to the filing of a lawsuit or claim against the applicant or said person? If you answered to Question 16 or 17, a supplemental claim application is required. The application is available at or phone our office ( ) to have it faxed or ed. te: If any such claims exist, or any such facts or circumstances exist which could give rise to a claim, then those claims and any other claims arising from such facts or circumstances are excluded from the proposed insurance. 18. Please check the coverage and limit of liability per claim and aggregate desired: Coverage Options Per Claim Limit Aggregate Limit Optional Coverage: Residential Only $300,000 Residential and / or Commercial $500,000 $1,000,000 Other $ $300,000 $600,000 $1,000,000 $500,000 $1,000,000 $2,000,000 (available only with $1,000,000 per claim limit) Other $ Real Estate Sales & Property Management (A copy of your real estate license and a supplemental real estate sales application is required. You may download this supplemental application at or phone LIA to request a copy.) The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands his application, and declares all statements set forth in this application and other information provided in this application are true, complete and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the effective date of the policy applied for, which may render any statement made in this application inaccurate, untrue, or incomplete, will be immediately reported in writing to LIA Administrators & Insurance Services. The undersigned acknowledges and agrees that the submission and LIA Administrators & Insurance Services receipt of such written report prior to the inception of the policy applied for, is a condition precedent to coverage. Signing of his application does not bind the insurance company to offer nor the applicant to accept insurance, but it is agreed that this application and all information provided in this applica ion shall be the basis of the insurance and it will be attached and made a part of the policy should a policy be issued. Applicant hereby authorizes the release of claim information from any prior insurer to LIA Administrators & Insurance Services (LIA) and/or the insurance company. Print Name (Principal/Owner) Signature Title Date Before mailing, please check that you have: 1. Answered ALL of the questions. (If not applicable, did you indicate N/A accordingly?) 2. Included resumes / qualification sheets for ALL principals, appraisers and trainees. 3. Completed the application by typing or printing your answers in black ink. 4. Included ALL required attachments for questions #11, 15, 16, 17 and / or Has the application been signed and dated by a principal, owner or officer? Page 3 of 4

4 STAFF ADDENDUM Customer ID: Full Name of Applicant: If more space is needed for Question 8, please complete the following for all additional persons working for or on behalf of the applicant. If you are applying as an individual or sole proprietor, you must list yourself in this section. Firms must list all principals, employees and independent contractors, regardless of the number of appraisals done. All clerical and support staff should also be listed. Status Codes: P Owner, Principal, Partner T Trainee Appraiser R Realtor ( coverage is applicable A Appraiser O Administrative, Support Staff until selected and bound; see Question 18 for details) te: Clerical and Support staff should be listed, and will be covered at no additional charge. Full Name Status Code Active (A) Inactive (I) Appraisers Certificate or License Number Commercial Currently Held Designations A resume/qualifications sheet must be submitted for all Principals, Appraisers and Trainees listed above. Page 4 of 4

5 Real Estate Appraisers Professional Liability False Information Page 1 of 2 LIA009 (08/11) LIBERTY INSURANCE UNDERWRITERS, INC. (A Stock Insurance Company, hereinafter the Company ) ALASKA APPLICANTS: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. A lack of the statement on a claim form does not constitute a defense to prosecution under this title. ARIZONA APPLICANTS: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. DELAWARE APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. IDAHO APPLICANTS: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete or misleading information is guilty of a felony. INDIANA APPLICANTS: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony. KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

6 Real Estate Appraisers Professional Liability MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW HAMPSHIRE APPLICANTS: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in section 638:20. NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OREGON APPLICANTS: Any person who makes an INTENTIONAL MISSTATEMENT that is MATERIAL TO THE RISK MAY BE found guilty of insurance fraud by a court of law. PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Page 2 of 2 LIA009 (08/11)