Real Estate App - ALIA Riverton Insurance Agency Corp.

Instructions
This policy applies only to claims first made against the insured during the policy period or discovery period. The limit of liability available to pay judgements or settlements shall be reduced by payment of defense costs. Defense costs are subject to the applicable retention. Please read and review the policy carefully.

Instructions: this self-rating application is for an individual appraiser who performs 100% real estate appraisals work. Please note that coverage will only apply to services rendered by the applicant.

The term "Applicant" shall mean all natural persons proposed for coverage.

Section A: General Information
Full Name of Applicant*
Official Business Name*
Official Business Address*
City*
State*
Zip*
County*
Primary Email Address*
Primary Phone*
Current/ Desired Effective Date*
Alternative Information about the Applicant*
Please describe any alternative business names, mailing/billing addresses or administrative contact information related to business activities other than the official ones listed above. If none, please enter “none”.
- In lieu of mailing my Policy, please Email the Policy to the address above. I agree to accept an electronic copy of my Application with my Policy.
- In lieu of completing multiple applications, I agree for this application to be used to place coverage with an alternative insurance company offering better coverage or lower rates for a comparable product.

Qualification
I'm sorry, but you no longer qualify for the Self Rating E&O Program.

Please call the ALIA Service Team at 1-800-882-4410 Extension 1 so we can renew your coverage in the Standard E&O Program.

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Calculate Your Premium
7. In the last fiscal year, 80% or more of my revenues have been derived from residential appraisals.*
- True
- False
8. Within the last fiscal year, I have not appraised any properties valued at greater than $3,000,000.*
- True
- False
9. The Applicant’s combined total gross revenues for the last three (3) years did not exceed $500,000.*
- True
- False
Additional Coverage Options (for a charge)
- Real Estate Trainee Coverage is available for 50% of the premium chosen from the table above
- Appraisal Management Company Extension (return completed application to your agent for final premium)

Summary
Your State: {state:83}

Your Selected Limits: {Please select your limits:43}
Premium
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Calculate Trainee
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Calculate AMC
Additional Coverages
ALIA Subscription ($10 a month billed annually)
Total Due
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Total amount Due with Downpayment
Please Read

This proposal is based on your enrollment in the ALIA Professional Education Subscription as itemized above. As a benefit to this subscription, your standard Deductible of $500 is reduced to $0 and additional coverage enhancements are provided. The premiums listed above are subject to change based on carrier fillings and should not considered final until written confirmation is obtained from the carrier.
E-Signature*
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Date
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Name
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Instructions