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Madison Wisconsin Real Estate Agents

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					                                                                Home Office:
                                                             Madison, Wisconsin
                                                             Administrative Office:
                                           8877 North Gainey Center Drive • Scottsdale, Arizona 85258
                                                               1-800-423-7675

           MORTGAGE BROKERING—TITLE INSURANCE AGENT SUPPLEMENTAL TO THE
              REAL ESTATE ERRORS AND OMISSIONS INSURANCE APPLICATION

                                     THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY

COMPLETE THIS SECTION ONLY IF MORTGAGE BROKERING SERVICES ARE PERFORMED
1. Is the Applicant a Certified Residential Mortgage Specialist? ....................................................................                      Yes     No

2. Is the Applicant involved in Underwriting, Servicing or Warehousing of Loans? ........................................                                  Yes     No

3. Does the Applicant fund loans of any type? ................................................................................................             Yes     No

4. Does the Applicant derive any income from services as an Escrow Agent? ..............................................                                   Yes     No

*STOP! If the Applicant answered “YES” to any of the above questions, this policy does not provide coverage for
these activities. Please contact George F. Brown at 888-372-6262 for alternative products that provide the
coverage you need.

5. What percentage of the Applicant’s gross income is derived from Loan Origination Fees? ......................                                                    %

6. What percentage of the Applicant’s gross Mortgage Brokering income is derived from:
     a. Sub Prime Lending? .............................................................................................................................            %
     b. Yield Spread Premiums? .....................................................................................................................                %

7. Number of Mortgage Brokers: Full-Time                                                 Part-Time                                Average yrs experience:

8. Has the Applicant ever been criticized, disciplined, fined or received a complaint from a Governmental
   Agency, a regulatory entity, an investor group, a Warehouse Wholesaler/Banker or HUD/VA? ...............                                                Yes     No
     If “YES,” please explain below.
9. a. Indicate the following loans handled in the last year:
       Service Area             No. of Loans                Total Value              Average Value                Maximum Value                % of Gross Receipts
        Origination                                                                                                                                                 %


     b. What percentage of mortgage brokering is done for current clients? ..................................................                                       %
     c. Provide a percentage breakdown of mortgages originated in the following areas:
                                                                                                                   Existing                   New Construction
       Residential                                                                                                                    %                            %
       Commercial                                                                                                                     %                            %
       Other (please describe)                                                                                                        %                            %
                                                                    Total Above must equal                                       100%                            100%

COMPLETE THIS SECTION ONLY IF TITLE INSURANCE AGENT SERVICES ARE PERFORMED
1. Number of Title Insurance Agents: Full-Time                                                       Part-Time
   Average yrs experience:



RT-APP-4 (10-08)
2.   List title insurance companies the Applicant represents and percentages of total premium written (please do not
     abbreviate):
                                                           Company                                                                        Percentage
                                                                                                                                                          %
                                                                                                                                                          %
                                                                                                                                                          %
                                                                                                                                                          %
                                                                                             Total Above must equal                                     100%
3. Has a title company ever cancelled or nonrenewed their agency contract with the Applicant? ..................                                  Yes     No
     If “YES,” please explain below.

4. Does the Applicant maintain an in-house title plant? .................................................................................         Yes     No
     a. If an in-house plant is not maintained, from what source is data compiled:
          Courthouse records? ................................................................................................   Yes      No               %
          Title Company Plant? ...............................................................................................   Yes      No               %
          Independent Searcher? ............................................................................................     Yes      No               %
                                                                                                                                 Total Above must equal 100%

5. Does the Applicant maintain a Grantor/Grantee Index? ..............................................................................            Yes     No
     If “YES,” is it maintained using software you designed? .............................................................................        Yes     No
     If “YES,” is it maintained using shared/purchased software? ......................................................................           Yes     No
 Please provide Additional Information here:




I understand that this supplement is attached to and is made part of the Real Estate Errors & Omissions
Insurance Application and is subject to the same representations and conditions.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.



                                 Signature of Applicant                                                                            Date


                             Title of Applicant

Agent Name: ___________________________________________________________ Agent License Number:
                                        (Applicable to Florida Agents Only)




RT-APP-4 (10-08)

				
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