Mortgage Brokers and Bankers E&O Insurance Application, E and O, Workers Compensation, Bond applications Maryland - Oxley-Goldburn Insurance Co.- Full service insurance company in Rockville, Maryland

-Applicant *
-Address *
-Addtl Address *
-Contact Name *
-City *
-State *
-Zip Code *
-Phone *
-Fax *
-E-mail *

How did you learn about us?

*Date of beginning business under present individual or firm name:

*Are you owned by, or affiliated with other companies, or do you have subsidiaries?
-Yes -No (If yes, please provide details)

*Have any claims been made or legal proceedings begun against the Applicant or any member of the firm?
-Yes -No (If yes, please provide an explanation)

*Are there any outstanding unsatisfied judgments against the Applicant?
-Yes -No (If yes, please explain or attach explanation)

*Please indicate the approximate percentages of your operations involving:

a. Loan Underwriting	%
b. Loan Servicing	%	#of loans	Volume of loans served
c. Loan Brokerage Only	%
d. Sub prime loans	%

*Do you have a warehouse line of credit? -Yes -No

If so , amount -

With Whom -

*Please provide the following information regarding your company's originated loans:

# of loans originated in the last 12 months -

Average loan value -

Maximum loan value -

Percentage of residential originations -

Percentage of commercial originations -

*Have any loans been repurchased by the applicant?

Yes No

*Does the applicant close loans without having an advanced written commitment
to purchase the loan(s)?

Yes No

*Does the applicant sub-contract real estate appraisals?

Yes No
(If yes, does the applicant verify they have Errors & Omission Insurance)
Yes No

*Does the applicant use independent contractors (1099 employees)?

Yes No

*Do you have a contract to service loans for:

Yes   No Fannie Mae
Yes   No Freddie Mac
Yes   No HUD

*Provide your company's estimated gross revenue for the coming year.

*What percentage of loans are funded directly by investors?

*Do you currently have Errors & Ommission Coverage	Yes No , If yes, Insurance Carrier Name
Limit Of Liability
Deductible
Premium
Policy Term
Retro Date

*Number of employees
*Years in Business
*Any EPL claims?	no yes
*Do you currently carry EPL	no yes

Please use the submit button below,
(include comments below),
or print this application and mail or fax
completed information to:

Oxley and Goldburn
204 Monroe Street, Suite 210
Rockville, MD 20850
301-251-1479 FAX

comments/add. info

INFORMATION PRIVACY We have a strict privacy policy. Information provided to us is held in confidence and it is used only for administration, sales, and underwriting with regard to the products we offer. We share your information with insurance company underwriters for the purpose of providing you the products that you have requested. Your information is not provided to anyone else without your written consent. All forms are submitted through a secure server.

>>>Mortgage Brokers & Bankers E&O Insurance Application