Williams Underwriting Group

1 2017-2019 ENROLLMENT FORMTENNESSEE REAL ESTATE LICENSEE PROFESSIONAL LIABILITYI warrant that I have made reasonable inquiry to provide the answers to the questions contained in this for m. I further warrant that all such answers are true ,correct and complete to the best of my knowledge and belief. Also, I understand that the cover age provided under this policy is claims-made cover age. If you haveknowledge of any error, omission, act circumstance or situation that may give rise to a claim, it must be reported to your current insurance company before yourcurrent policy period expires. The new insurance company is not obligated to defend or pay where there is knowledge of a claim or potential claims before thebeginning of the policy FORM MAY BE COPIEDPART I: INDIVIDUAL LICENSE ENROLLMENTREAL ESTATE LICENSE #PART III: TENNESSEE RESIDENTS - DO YOU NEED REAL ESTATE CERTIFICATION TO ANY OF THE FOLLOWING STATE MANDATEDINSURANCE PROGRAMS IN ANY OF THESE STATES - CO, IA, ID, KY, LA, NE, ND, NM, RI, SD OR WY?

2 If you need certification to Mississippior if your firm needs coverage certification to any of the above states, contact WUG at 800-222-4035 for T O: Williams Underwriting GroupAssured NL Insurance Agency, LLC2211 River RoadLouisville, KY 40206 NAME AS STATED ON LICENSEMAILING ADDRESSCITYSOCIAL SECURITY NO.* (Required by TREC for feeds)FAXZIP CODESTATEPART II : OPTIONAL FIRM LICENSE ENROLLMENT (COMPLETE ONLY IF PAYING FOR FIRM) Bro ker s and individuals must st ill apply forindividual c NAME STATED ON LICENSE (Legal Name - NOT DBA Name)ADDRESSCITYBUSINESS PHONEZIP CODESTATEA pplies only to Corporation, Partnership or LLCLast 4 digits onlyPAYMENT INSTRUCTIONS:Enroll online at Make Check Payab le to: Williams Underwriting Group (a $ convenience fee will be added to enroll on-line)Firm Lic.

3 #SEE REVERSE SIDE FOR PREMIUMSPART IV: Do you have a professional liability insurance policy currently in force cover ing your duties as a real estate licensee thatwill expire during 2017 or 2018?NOYESIf Y es please provide the following infor date do you request your cover age under this policy to become effective? _____Insurance DatesRetroactive Date _____ (1st date of continuous insurance cover age with no gaps in cover age. If not known put TBD)NOYES - If Y es list the state(s) and license number for each NumberStateLicense NumberStateLicense NumberStateLicense NumberE-MAILBUSINESS PHONEWARNING: Licensee who do not obtain an E&O Policy by January 31, 2017, will lose any previously established retroactive date (Prior Acts coverage).

4 Your newef fective date and retroactive date will be the 1st of the month in which your payment is TYPE: PRINCIPLE BROKER BROKER AFFLIATE BROKER TIMESHARE WUGW illiams Underwriting GroupNOTICE: ALL PERSONS WITH AN ACTIVE real estate license (hereafter referred to as licensees) must maintain a policy ofprofessional liability (errors & omissions) insurance to obtain or renew an active E&O policy provides the minimum TREC required limits of $100,000/$300,000 or your choice of limits as shown below. All limits aresubject to a $1,000 paid claim deductible per ACTIVE REAL ESTATE LICENSEES who are ALSO APPRAISERSmay purchase an Endorsement to include appraisal activitieswith your real estate coverage.

5 Note: You must hold and maintain an active Tennessee real estate license for this coverage to INDICATE YOUR CHOI CE OF LI MIT S AND MONTH/YEAR COVERAGE I S TO BECOME EFFECTI VE BY CHECKING THEAPPROPRIATE BOX to 1-1-2019 PAYMENT TABLE$100,000/ $250,000/ $500,000/ $300,000 $750,000 $1,000,000Pr orated Premium Chart $100,000/ $250,000/ $500,000/ $300,000 $750,000 $1,000,000 January$122$193$236 February$112$177$216 March$102$161$196 April$ 92$145$177 May$ 81$129$157 June$ 71$113$137 July$ 61$ 97$118 August$ 51$ 80$ 98 September$ 41$ 64$ 79 October$ 31$ 48$ 59 November$ 20$ 32$ 39 December$ 10$ 16$ 20 January$244$386$471 February$234$370$451 March$224$354$432 April$214$338$412 May$203$322$393 June$193$306$373 July$183$290$353 August$173$273$334 September$163$257$314 October$153$241$294 November$142$225$275 December$132$209$255 Williams Underwriting Group , a Division of Assured NL Insurance Agency, LLC is the program administrator for a professionalliability (E&O)

6 Policy underwritten by a Zurich American Insurance Company, currently rated A+ (Superior) XV by Best. Alllicensees and firms are eligible for this coverage. Williams Underwriting Group will certify your compliance with the law directly to theReal Estate ENROLLMENT FORMTENNESSEE REAL ESTATELICENSEE PROFESSIONAL LIABILITYIMPORTANT NOTICE: ALL PREMIUMS WILL BECOME FULLY EARNED ONCE COVERAGE IS IN EFFECT. Enrollment can be made on-line AMEX, Visa, Mastercard or Discover accepted. There is a $ convenience fee for on-line enrollment Credit card payments will not be accepted by mail, phone, fax or Appraisal Coverage (Individual only) $2001-1-2018 to 1-1-2019 PAYMENT TABLEAdd Appraisal Coverage (Individual only) $1006.

7 Total premium $_____Premium Chosen for Firm: ..$_____Add Personal Identity Coverage (Individual only) $ 30 Add Personal Identity Coverage (Individual only) $ 15In order for you to be compliance with the TREC certification requirements all premiums and invoices must be received by December 16th to assureyour certification to the commission by their deadline. Payments received after December 16, 2016, may be subject to a late renewal fee as imposedby the TREC. Neither Williams Underwriting Group nor the insurance company will be responsible for any delay in the issuance of a license or certificatewhere forms and payments are received after December The box check ed above is your premium $_____2.

8 If you are also paying for the company (firm) please complete Part I I on the reverse side and add the premium for the + $_____3. Appraisal Endorsement- must have active real estate license (individual licensee only) - add $ + $_____4. Personal Identity Coverage (individual licensee only) - add $ + $_____Optional Coverages A vailable: 2017-2019 Ter mAdd Contingent Bodily Injury and Property Damagefor Real Estate Services including Property Management Services $ 50 Add Contingent Bodily Injury and Property Damagefor Real Estate Services including Property Management Services $ 255. Add Contingent BI/PD for Real Estate including Property Management Services - add $50 Individual- add $50 Firm- add $100 Both+ $_____