Title Agent Errors & Omissions Insurance Policy Premium Indicator

SECTION 1: GENERAL BUSINESS INFORMATION
Name of Applicant Agency: 
Date Established:
Address
Street Address
Address 2
Postal Code
City
State
Contact Person: 
Title:
Phone: 
Fax:
Email:
# of years of experience and name for each Principal/Partner (provide by separate attachment if needed):
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Is the Applicant owned by or have any ownership interest in a financial institution, mortgage company, real estate development or investment firm or a title insurance carrier?
If yes, does the Applicant provide any services to or for these affiliated entities?
Does the applicant perform 1031 tax deferred exchange services?
List states where the Applicant performs professional services:
Does applicant utilize sub-contractors?
Is proof of E &O insurance required of all sub-contractors?
SECTION 2: BUSINESS OPERATIONS
Gross revenues last 12 months $
Percentage of revenue from services
Title Insurance Agent
Abstracting Services
Escrow/Closing Services
Other (describe)
Provide the % of annual gross revenue by property type:
Residential
Commercial
Construction Loans
Oil & Gas
Mineral Rights
Other (describe)
SECTION 3: CURRENT INSURANCE COVERAGE INFORMATION
Effective Date (mm/dd/yyyy)
Carrier
Limits $
Deductible $
Premium $
Retroactive or Prior Acts Date
SECTION 4: PRIOR CLAIMS AND POLICY EXPERIENCE
Have any prior E & O insurance policies been cancelled or non-renewed?
Have you had any E & O Claims in the past FIVE years or do you have knowledge or information of any act, error or omission that

If YES to any of the above, provide details on a separate sheet of paper. A current loss run may be required.

**Please include an unaltered copy of your current declarations page if currently insured

Each proposed insured represents that the statements set forth in the form are true and correct and that no material facts have been suppressed, misstated or omitted.

Date (mm/dd/yyyy)
Title
Applicant’s Authorized Signature

NOTE: This form is for estimating purposes only. Coverage may be bound only upon submission and acceptance of a completed new business application.