SUPPLEMENT FOR MORTGAGE BROKERS 
All questions MUST be completed in full. 
If space is insufficient to answer any question fully, attach a separate sheet.  

1.	Full name of Applicant:  	
2.	For all mortgages handled by the Applicant, provide the percentage of total services provided: 
(a)	Origination Only		%
(b)	Underwritten  		%
(c)	Packaged and Sold 		%
(d)	Servicing 		%
(e)	Other (specify)  			%
3.	Does the Applicant or any organization controlled by, owned by, or commonly owned, affiliated or associated with the Applicant:
	(a)	currently provide loan funding, including partial funding or short term funding, or have an in-house
			line of credit?	[   ] Yes   [   ] No
	(b)	in the last five years provided loan funding, including partial funding or short term funding, or
		had an in-house line of credit?	[   ] Yes   [   ] No
4.	(a)	Does the Applicant hold the appropriate licenses in the states which require Mortgage Brokers/Correspondents to be licensed? 	[   ] Yes   [   ] No
	(b)	In which states is the Applicant licensed? 	
(c)	In which states does the Applicant operate where they are not licensed? 	
	(d)	Has the Applicant’s license ever been suspended, placed on probation, revoked or restricted in 
			any way?	[   ] Yes   [   ] No
				If Yes, provide details:	
			
5.	(a)	Does the Applicant hold funds in escrow?	[   ] Yes   [   ] No
	(b)	If Yes, does the Applicant hold these fund in a fiduciary account? 	[   ] Yes   [   ] No
6.	Limit for Fidelity Bond: 	
7.	(a)	Does the Applicant or any organization controlled by, owned by, or commonly owned, affiliated or associated with the Applicant perform property appraisals?	[   ] Yes   [   ] No
	(b)	If Yes, provide details.	
				
8.	What procedures does the applicant have in place to assure timely and proper disclosure of Good Faith and Truth in Lending Estimates? 	
			
9.	Is the Applicant aware of any violation or potential violations of laws in the following areas:
	(a)	Real Estate Settlement Procedures Act?	[   ] Yes   [   ] No
	(b)	Truth in Lending?	[   ] Yes   [   ] No
	(c)	Equal Credit Opportunity?	[   ] Yes   [   ] No
10.	(a)	Does the Applicant receive compensation from yield spread premiums (YSPs)?	[   ] Yes   [   ] No
If Yes, answer the following.

(b)	For each period indicated, state what percentage of the Applicant’s revenue is/was derived from YSPs?
		Projected for the coming year:		
		This year:		
		Last year:		
		Two years ago:		
	(c)	Describe the procedures in place for disclosing the yield spread premium to the borrower.	
			
11.	(a)	Has the Applicant ever been denied a written correspondent or loan broker agreement with a 
a lender?	[   ] Yes   [   ] No
	(b)	If Yes, provide details. 	
			
12.	(a)	Has any mortgage lender ever cancelled or withdrawn a written correspondent or loan broker
agreement? 	[   ] Yes   [   ] No
	(b)	If Yes, provide details. 	
			
13.	(a)	Total dollar value of mortgages brokered during the last 12 months: $	
	(b)	Number of mortgages closed during the last 12 months 	
	(c)	Dollar amount of largest loan closed in the last:	12 months: $ 	
			24 months: $ 	
			36 months: $ 	
	(d)	Provide the percentages for each mortgage type. (Need not equal 100%.)
		(i)	Conventional		%	Government 		%
		(ii)	1st Mortgages		%	2nd Mortgages		%
		(iii)	Owner Occupied		%	Non-owner Occupied		%
		(iv)	Purchase			%	Refinance		%
		(v)	Conforming		%	Non-conforming		%
	(e)	Provide the percentages for each mortgage type for each period indicated. (Need not equal 100%.)
			Prior 12 Months	Prior 24 Months	Prior 36 Months
		(i)	Reverse Mortgages		%		%		%
		(ii)	Interest only		%		%		%
(iii)	Prime (A paper)		%		%		%
(iv)	Sub-Prime (B or below)		%		%		%
(v)	Residential		%		%		%
(vi)	Commercial		%		%		%
(vii)	Fixed rate		%		%		%
(viii)	Adjustable rate		%		%		%
14.	(a)	Does the Applicant receive referrals from a parent company or any organization controlled by,
		owned by, or commonly owned, affiliated or associated with the Applicant?	[   ] Yes   [   ] No
	(b)	If Yes, provide details. 	

15.	(a)	Has the Applicant ever closed a loan with a lender that is currently in bankruptcy or no longer 
in business? 	[   ] Yes   [   ] No
	(b)	If Yes, list the defunct mortgage lending company(ies) the Applicant represented and the number of loans placed with each:
Company(ies)		Number of Loans

					
		
Signing this Supplement does not bind the Company to provide or the Applicant to purchase the insurance.

It is understood that information submitted herein becomes a part of our application for insurance and is subject to the same declarations, representations and conditions.

Must be signed by director, executive officer, partner or equivalent within 60 days of the proposed effective date. 

Name of Applicant		Title
			
Signature of Applicant		Date