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Contact Information
Broker First Name:
Broker Last Name:
Firm Name:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Phone:
Email:
Firm Information
Date broker licensed as a broker:
(mm/dd/yyyy)
Date broker licensed as an agent:
(mm/dd/yyyy)
Date firm established:
(mm/dd/yyyy)
Average value of properties sold:
$
Have any licensees of the firm had their license cancelled or revoked in the last 3 years?
Yes
No
Do you currently have E&O Insurance?
Yes
Current carrier:
Renewal date:
(mm/dd/yyyy)
Deductible:
$
Limits:
$
Years of continuous coverage:
Annual premium:
$
Is the firm independently owned and not controlled, affiliated with, or owned by another entity?
Yes
No
Are you a franchise?
Yes
With what company?
Do you always offer home warranty programs?
Yes
No
In what percentage of transactions do you represent both the buyer and seller?
%
Has the firm's name ever changed?
Yes
List prior name(s):
Number of licensed agents:
(include owners and managers)
Agents earning $20,001 or more in commission:
Agents earning $20,000 or less in commission:
No income:
(no commission income)
Number of agents with professional designations:
Claim Information
Any claims in the last 5 years?
Yes
Date of claim:
(mm/dd/yyyy)
Amount paid:
$
Percentage of Commissions
(Must total 100%)
Residential:
Commercial:
Other:
Real Estate:
%
Real Estate:
%
Farm/Ranch:
(income producing)
%
Raw Land:
%
Raw Land:
%
Auctioneering:
(residential and commercial)
%
Appraisals:
%
Appraisals:
%
Mortgage Brokerage:
%
Property Management:
%
Property Management:
%
Owned Property:
%
Owned Property:
%
Gross commission for the last 12 months:
(projected 12-month gross commission if new firm)
$
© Pearl Insurance 2008
1200 E. Glen Avenue, Peoria Heights, IL 61616 ph. 800.289.8170