E&O Claim Reporting Form

1405 S Fern St #96426 Arlington, VA 22202

(443) 502-5645
[email protected]

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Why PBI Group?
Coverage Insights
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GET STARTED TODAY!

E&O Claim Reporting Form

Home » E&O Claim Reporting Form

E&O Claim Reporting Form

(Not sure if you want to file a claim? Click here to help make up your mind. )

"*" indicates required fields

Step 1 of 4 - Insured Information

Insured Information

Your Company Name*

Policy # (no dashes)*

Name of Person at your Company To Discuss This Claim*

First Last

Phone*

Email*

Need to Add a 2nd Company Contact Person?

Yes

2nd Contact Name

First Last

2nd Contact Phone

2nd Contact Email

Need to Add a 3rd Company Contact Person?

Yes

3rd Contact Name

First Last

3rd Contact Phone

3rd Contact Email

Need to Add a 4th Company Contact Person?

Yes

4th Contact Name

First Last

4th Contact Phone

4th Contact Email

Did you represent the buyer or the seller?*

Name of your Agent involved in this matter*

First Last

Approximately how many years has the agent/s involved in this transaction been licensed as a real estate agent?*

Transaction Details

Type of Transaction*

Residential sale (non-mobile home)

Residential sale of mobile home

Commercial sale

Leasing

Long term Lease (1 year or more)

Property management (Com OR Res)

Short term vacation or weekly rentals

Foreclosure, REO or short sale

Business Brokering

BPO

Appraisal

Vacant Land /Lot

Other

Other Type of Transaction Description*

Property Address Involved in Transaction

Street Address Address Line 2 City State ZIP Code

What was the approximate final sale price $ if closed, or approximate listed sale price $ if not?*

No $ signs

Did the Transaction Involve any of the Following?

An estate sale or purchase?*

Yes

A dual-agency, intermediary, transaction brokerage, in-house transaction, or in any way did your firm collect commission on both sides of this transaction?*

Yes

Seller property condition disclosure completed?*

Yes

An agent-owned property?*

Yes

If yes, Involved agent-owned property*

Was the buyer or seller an attorney?*

Yes

Unknown

Home inspection*

Performed

Waived in Writing

Unknown

Not Applicable

Home Warranty*

Purchased

Waived in Writing

Unknown

Not Applicable

Complaint / Claim Information

Name of Plaintiff(s)/Complainant(s):*

Nature of the Complaint or potential complaint:*

Please check all boxes applicable to the transaction in question:

Failure to advise previous water or flood damage

Bodily injury

Property damage or repairs needed to be done to property

Fair Housing discrimination

Subpoena response

Incorrect square footage / acreage

Permit /Intended Use

Earnest money dispute

HOA assessments or other HOA-related issues

Sewer / Septic / Water Supply / Gas / Solar / Utility

Pollution (mold, lead, radon, asbestos, etc.)

Easements

Association of Realtors complaint or other regulatory body

Other

Type of Pollution*

Other Pollution Description*

Brief Narrative describing the circumstances leading to the claim, demand or potential claim*

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PBI Group

1405 S Fern St #96426
Arlington, VA 22202

Office

443-502-5645 (office)
888-600-4130 (fax)

Email

[email protected]

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E&O Claim Reporting Form

E&O Claim Reporting Form

Insured Information

Transaction Details

Did the Transaction Involve any of the Following?

Complaint / Claim Information

PBI Group

Office

Email

Real Estate Insurance in Your State

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