PROFESSIONAL LIABILITY INSURANCE INDICATION REQUEST
 
For Real Estate Professionals
 
 
 
 
 
 
First Name*
 
 
Last Name*
 
 
 
Email*
 
 
Phone*
 
 
 
State*
 
 
 
 
 
 
 
I am a:*
 
 
 
 
 
 
How many agents are working under your brokerage?*
 
 
 
 
 
 
How many years has your brokerage been operating?*
 
 
 
 
 
 
Have there been any claims, complaints, disciplinary actions against your firm?*
 
 
 
 
 
 
What is your firm’s gross annual revenues (total firm commission revenue)?*
 
 
 
 
 
 
Do you currently have a Professional Liability Insurance Policy?*
 
 
 
 
 
 
Upload declarations page if you already have coverage. If you do not have a declarations page or current coverage, please click Submit and an application will be emailed to you.
 
 
 
 
 
 
Provider Name
 
 
 
Current Premium
 
 
 
Renewal Date
 
 
 
 
 
 
Association Referral
 
 
 
Agency