From: Subject: Online Renewal Date: Tue, 27 Jan 2009 14:17:09 +0530 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_000C_01C98089.F1079290" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_000C_01C98089.F1079290 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: mhtml:file://C:\Documents and Settings\sshah\Desktop\Online Renewal.mht Online = Renewal
Black Ink Insurance - Online Renewal Form=20
Company Name:
 
Phone:
  =
Fax:
 
Email:
  
Address:
  
City:
  
State:
  
Zip:
  =20

 

Do You Have Multiple Office Locations:

NO = YES (If yes, program will ask for them one = at a time=20 until all have been entered.)


Is the Applicant a:

Corporation Partnership = Sole=20 Proprietorship Independent Contractor =


Has there been any ownership changes, change in address, = additional=20 company names added, or branch offices added during the past year=20 ?

NO = YES=20

If =93YES=94 =96 PLEASE COMPLETE CHANGE IN OFFICE = STATUS FORM BELLOW=20

 

Brokers Name:
 
Years Licensed As a Broker:
  =20
Date Firm Was Established:
 
Years Licensed As an Agent:
   =
   
Principal Owner:
   =

 

2. Number of staff:

     
Brokers: Agents: Property = Management: Clerical:

Agent:
  =
Agent:
  =
Agent:
  =
Agent:
  =
Agent:
  
More:
  NO =20 YES


3. Gross Income:

Description:
Gross Income
Last 12 = Months
Number of Transactions Closed Or Units=20 Managed
% Sold with Warranty
Projected Income
Next 12 = Months
Residential (including family owned farms) $ = = $ $
Commercial (including residential over 5 units) $ = = $ $
Vacant Land Zoned for Residential Usage $ $ $ =20
Vacant Land Zoned For Commercial Usage $ $ $ =20
Business Brokerage $ = = $ $
Property Management Fees (Residential) $ $ $ =20
Property Management Fees (Commercial) $ $ $ =20
Farm Management Fees $ $ $ =20
Real Estate Leasing Fees (Property Not Managed) $ $ =20 $
Real Estate Appraisal Fees (Residential) $ =20 =20 $ $
Real Estate Appraisal Fees (Commercial) $ =20 =20 $ $
Real Estate Consulting $ $ $ =20
Real Estate Mortgage Brokerage $ $ =20 $
Referral Fees $ =20 =20 $ $
Other (Describe) $ $ $ =20
TOTAL:
$ = = $ $ =20



4. E&O policy in effect?=20 YES - BLACK INK=20 INSURANCE

 

5. Have any claims been made during the last five years = or are=20 you aware of any circumstance which may result in a claim being = made=20 against the applicant or broker?

NO = YES

IF =93YES=94 WAS THIS REPORTED TO = BLACK=20 INK?

NO YES

IF =93YES=94 = WHEN WAS=20 IT REPORTED? =20


CHANGE IN OFFICE STATUS

 

Present Company = Name: =

1. The following changes have = transpired:

New Phone:
 
New Fax:
  =
New Contact Person:
 
Email:
  
Address Changed to:
  
City:
  
State:
  
Zip:
  =
Date of add. Change:
        
New Company Name:
  
Date of Name Change:
  


Is this a result of an = ownership=20 change?
NO YES
 
If yes, date of ownership change:  
Has there been a merge or acquisition?
NO YES
 
If yes, date of merge:  

2. Branch Information:


Have you opened a new Branch = office?
NO YES
 
If yes, please give date opened:  

Address of new Branch office:		    

Address:
  
City:
  
State:
  
Zip:
  =

Will the name of the Branch = office be=20 the same as the Present Company Name?
NO YES
 
If no, what is the New name?  
How many agents will be in this office?  

Phone of New Branch office:
 
Fax of New Branch office:
  =
Contact of New Branch office:
 
Emai of New Branch office::
   =

 

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