Mortgage Brokers Professional Liablity

Applicant's Information

Firm or Company Name:

Entity:

Full Name of Contact:

Phone Number:

Fax:

Street Address:

Address (Cont.):

City:

State:

Zip/Postal Code:

Email:

Year Established:

Website:

Current Policy Information

Current Professional Liability Carrier:

Limit:

Deductible:

Expiration Date:

Retro Date:

Premium:

Underwriting Questions

Is a client contract or engagement letter?

Are 100% of clients required to sign a contract?

If no, what

Does the applicant's key professionals hold licenses/certifications?

Does the applicant attend professional association seminars?

Does the applicant hold regularly scheduled meetings with clients?

Does the applicant have affiliation, ownership or association with any firm or other entity?

Does the applicant currently have General Liability insurance?

Does the applicant engage in professional activity other than that described?

Does the applicant use independent contractors/subcontractors?

Number of Principals:

Number of Technical/Professional Staff:

Number of Clerical/Administrative Staff:

Total Employees:

Amount of Applicant's Gross Receipts/Gross Fees

Last Year:

This Year:

Projected for the Coming Year:

Number of loans processed over the last 12 months:

Zip:

Exhibitor Details

Booth Size (Square Feet):

Type of Exhibitor:

	Exhibitors - No Sales
	Concessionaires - Food Sales
	Concessionaires - Non Food Sales

Coverage Options

Date of Coverage:

Remember to include load-in and breakdown days.

Number of Days:

General Liability

General Liability Limit:

Products Liability:

Required Only for Concessionaire - Non Food Sales

Liability Options:

	Blanket Additional Insured
	Certificates of Insurance
	Waiver of Subrogation

Property Coverage

Third Party Property Damage:

Notes


*Mortgage Brokers Professional Liability Application*

	Please complete the appropriate fields in the form below. After verifying the accuracy of the information, click on the 'Submit Application' button. Feel free to contact David Merrill at (626) 795-992 with any questions or concerns.
	Complete this form only if your business is located in California

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