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>>>Title Agents Professional Liability Insuance Application

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In order for us to provide an accurate estimate for this type of insurance all areas of this application MUST BE COMPLETED.
*Required

*Name:
*Address1:
*Adress2:
*City:
*County:
*State:
*Zip Code:
*Phone:
Fax:
*Email:
 
How did you learn about us?
*Are there other offices?  -Yes -No
If Yes please list (include county)
LIST HERE:
*Date Established:
 
* 1.Have you changed the name of the firm, purchased, acquired, been acquired by, mergerd with, or consolidated with any other firm in the last 5 yeas?
-Yes -No
If Yes, please explain below:
EXPLAIN HERE:
 
* 2. Does any person or entity with any equity or ownership interest in the title agency also own, control, manage, or operate any construction business, real estate investment or development company, financial institution, or title insurance carrier?
 -Yes -No
If Yes, please explain below:
EXPLAIN HERE:
* 3. Are any of the principals or key employees actively involved in any business or profession other than title agent, escrow agent, abstractor, etc. or is any other type of business or profession conducted?
 -Yes -No
If Yes, please explain below:
Explain Here:
*4.TITLE ACTIVITY
Gross Revenue		 LAST 12 MONTHS
*a. Escrow Services  $ 
*b. Title Agent Commissions/
Abstracting/Search Fees		  $ 

c. Other		  $ 
Explain:
TOTAL GROSS REVENUE  $ 
* 5. During the past two years, have you handled disbursement of funds as contruction progressed, or have you handled any periodic disbursement type escrows?
-Yes -No
If Yes, please provide explaination including percentage of gross revenue emanating from these clients below:
Explain Here:
* 6. Has any perosn at the firm ever had any professional or business license of any kind suspended or revoked?
-Yes -No
If Yes, please explain below:
 
Explain Here:
* 7. Prior Coverage - List all title agents professional liability insurance carried during the past five years. If none, state "none".
Ins. Co. Limit Liability Deductible

Premium
 Policy Period
* 8. Has any application for title agents errors and omissions insurance on behalf of the applicant or any predecessors firm been declined, or has any policy been cancelled or nonrenewed?
-Yes -No
If Yes, please explain, including specific reason for cancellation or nonrenewal below:
Explain Here:
   
INFORMATION PRIVACY We have a strict privacy policy. Information provided to us is held in confidence and it is used only for administration, sales, and underwriting with regard to the products we offer. We share your information with insurance company underwriters for the purpose of providing you the products that you have requested. Your information is not provided to anyone else without your written consent. All forms are submitted through a secure server.
   

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