*Denotes a required field

Policy State*: Check the state(s) in which you are enrolled with RISC

AlaskaColorado - AppraiserColorado - Mortgage Loan OriginatorColorado - Real Estate BrokerIdahoIowaKentuckyLouisianaMississippiMontanaNebraskaNew MexicoNorth DakotaRhode IslandSouth DakotaTennesseeWyoming

Name & License number: This is the best way for us to locate your information in our system. Please provide your name as it appears on your license, no nicknames. If you are changing your name or license number, please provide the original name and license number as well, so that we can locate you in our database.

Full Name*

License Number*

Real Estate Firm*: This should be the name of the firm where your license hangs. If your license hangs independently you may enter "self".

Mailing Address: Please provide the mailing address that is best to reach you if we need to do so. In most circumstances, if you are domiciled in a state other than the policy state, your insurance is limited to professional services provided in the policy state. Please see Section V. Territory of the policy for further information. Please note, the Real Estate Commission provides the addresses for the renewal mailings in most states where we have the state contract.

Line 1*

Line 2

Phone Numbers: Please provide your phone numbers so that we may contact you if needed. If you do not have a phone number for one of the listed items, you may leave it blank.

Your Email*: Please provide your email address so that we may contact you if needed. RISC will never sell your email address to other companies.

*We occasionally send important notices by email. To receive these notices, add our email domain (@risceo.com) to your address book.*

Remit Updated Certificate To*: Please indicate if you would like to receive this via email, fax, or both.

EmailFax

Remit Email/Fax:**Enter only if different from above**

Additional Information

ACKNOWLEDGEMENT
I acknowledge that the above information is correct and authorize RISC to make the above changes to my policy. I understand that this form applies to my E&O insurance policy administered by RISC ONLY and not my licensing information through the Real Estate Commission. I will still contact the respective Commission to update my contact information with them. **PLEASE NOTE: Enrollment forms are only sent out utilizing the data received from the Real Estate Commission per our contract.**

Please leave this field empty.