Mortgage Field Services

National Association Mortgage Field Services Inc.
Mortgage Field Services Contractors Supplemental Questionnaire


Make sure you complete all fields before submitting.
Click on Submit when ready to send.

* Required Fields
  • * Applicant Name:
  • Business Name:
  • * Email Address:
  • Address:
  • * City:
  • * State:
  • * Zip:
1. Is the applicant a NAMFS member (National Association of Mortgage Field Services)
Yes   No  

A. List below by names the Mortgage Field Service Companies, Banks, Mortgage Companies or Realtors for whom you perform mortgage field services and the percentage of income derived from these companies:

List all companies that will require certificates of Insurance from you.

Company Percentage of Income (%)
* *

B. List below by name any other clients that you perform the operations in question 3 for and the percentage of income derived from these companies:

Company Percentage of Income (%)
* *

2. A. Estimated Annual Gross Sales for the next 12 months *
    B. Estimated Annual Gross Sales for the last 12 months *

3. Provide a percentage breakdown of your annual receipts, falling within the following categories:
a. Residential Property Inspections % f. Vacant Property Reports %
b. Delinquent Borrower Interviews % g. Property Preservation Services %
c. Commercial Property Inspections % h. Property Preservation and
     Repair Estimates
%
d. Insurance Loss Draft Inspections % i. Property Rehabilitation Service %
e. Evictions % j. Merchant Site Verifications %
For Contractors who Perform Grass Cuts Only Check Here

4. Provide percentage of work performed on:
Private Residences %   Commercial Properties %

5. If you perform operations other than those listed in question 3, provide a description of these operations and applicable annual receipts.


6. Do you use independent Contractors?   Yes   No

If yes, provide a description of the operations they perform.
Estimated annual contract costs:
Do you require they carry Liability Insurance limited at least equal to your own?
  Yes   No

7. Do you obtain Certificates of Insurance?   Yes   No

8. Are you required to provide Hold Harmless Agreements?   Yes   No
If yes, provide a sample of the most common wording.

9. Do you perform and services or work in New York?   Yes   No
If yes, Does any work/services provided involve any roofing work or work outside at height regardless of whether done by the applicant or sub-contracted out?  
Yes   No
If yes, describe

10. Provide a description of any contracting, maintenance or service equipment used in the performance of your service.


11. Provide number of: Officers:   Partners:   Employees:

12. Do you perform reference and security checks on all employees?   Yes   No

13. Do you have formal training procedures for employees that perform inspections and/or interviews?   Yes   No If yes describe:


14. Years in business:

15. Phone #   Fax #

16. Type of business: Corporation: Individual: Partnership:
                               LLC: NonProfit: Other: If Other Describe:


17. Current Insurance Company: Type of Insurance:
Retroactive Date: Current Premium: If none check here:


Loss History


has not had any claims made/ suits filed, or circumstances notified that I am/ we are aware could become claims against me/ us in the last thirty six months. In the case of a corporation, diligent inquiry must be made of all persons that could have knowledge of claims or circumstances and this declaration is made on behalf of all such persons.

Enter All Claims, Occurrences, or Circumstances that may give rise to claims for the prior thirty six months: Check here if none
Check here if emailing loss summery

Date of Occurrence Type and description of claim,
Occurrence or Circumstances
Amount Paid Amount Reserved


PROGRAM

SERVICE FEE AGREEMENT


The undersigned hereby acknowledges that a $50.00 service fee for revenues under $50,000 and a $200.00 service fee for revenues over $50,000 will be included in the total premium that is shown on the quotation. A service fee is not charged to obtain a quote.

This fee is for the underwriting, policy issuance, and subsequent issuance of certificates of insurance. It also includes the mitigation and management of claims and excess and surplus lines tax filings.

Submitting this agreement indicates your acceptance of its terms.

Name:
Title:
Company Name:
Date:

In the advent of a mid-term cancellation. At the request of the insured. Services fees are non-refundable.

SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE


YOU HAVE THE RIGHT UNDER THE ACT TO SELECT OR REJECT THIS TERRORISM COVERAGE. YOU MAY SELECT THIS COVERAGE BY INDICATION YOUR SELECTION AND PAYING THE ADDITIONAL PREMIUM AS INDICATED BELOW. YOU MAY ALSO CHOOSE TO DECLINE THIS COVERAGE, BY INDICATING YOUR CHOICE BELOW, IN WHICH EVENT YOU WILL NOT BE CHARGED ANY ADDITIONAL PREMIUM. IF YOU DECLINE THIS COVERAGE, YOU WILL NOT BE COVERED FOR LOSSES ARISING FROM ANY ACT OF TERRORISM, INCLUDING CERTIFIED ACTS OF TERRORISM UNDER THE TERRORISM INSURANCE ACT OF 2002.

I hereby acknowledge that I have been notified that under the Terrorism Risk Insurance Act of 2002, that any losses caused by certified acts of terrorism, should I elect to purchase such coverage, will be partially reimbursed by the United States government and I have been notified of the amount of additional premium attributable to such coverage.

(please select one)
I hereby elect to purchase coverage for certified Acts of Terrorism for the Additional Terrorism Risk Premium shown in this notice.
I hereby elect NOT to purchase coverage for certified Acts of Terrorism and understand that I will have no coverage for losses arising from any certified acts of terrorism.
  • Policyholder's/Applicants Digital Signature: (Please type name)
    *
  • Date:
Please indicate your selection of rejection of the option to purchase the coverage described in the space indicated above; digitally sign and date the notice and submit. Please print a copy of the completed notice for your records. Please include any documents pertinent to this application:

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Other Key Services

Auto/Home

York-Jersey Underwriters represents 15 auto and homeowner insurers. We always provide multiple quotes from a variety of companies to ensure you are receiving the best service and highest value. You can be assured that your independent agent has your best interests in mind.

Business

From Wall Street to Main Street, we insure businesses of all sizes. Whether you are a retailer, wholesaler, contractor or manufacturer, we have the expertise to tailor your coverage plans to meet your particular needs. By representing many of the leading national and regional insurance companies, we can design a comprehensive protection plan that works for your bottom line.

Life/Health Employee Benefits

York Jersey Underwriters also specializes in employee benefits. Our organization has a team of employee benefit specialists who have over 30 years of combined experience with group benefits. Our employee benefit specialists focus on reducing employer cost without decreasing employee benefits.

Mortgage Field Services

York-Jersey Underwriters has insured the mortgage field service industry since 1983 and has the endorsement of the National Association of Mortgage Field Services (NAMFS). This is the oldest, largest and only not-for-profit field service association in the country.