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PROFESSIONAL LIABILITY INSURANCE APPLICATION
TITLE AGENTS ERRORS & OMISSIONS
(CLAIMS MADE BASIS)
DEFENSE COSTS ARE INCLUDED WITHOIN THE LIMITS OF LIABILITY
INSTRUCTIONS:
* ANSWER ALL QUESTIONS COMPLETELY AND ATTACH SEPARATE SHEETS AS REQUIRED; INCOMPLETE OR
illegible applications may be discarded
* Application must be signed and dated by the partner, owner, or officer not earlier than 45 days before the proposed effective date of
coverage.
1. Applicant:
Address:
City:
Phone Number:
State:
Zip Code:
Fax Number:
E-Mail Address:
Web Address:
2. Are there other office locations?
a. If Yes, please list:
3. Applicant is
If "Other" was selected, describe:
4. Date Established:
Contact Person/Title:
5. List Ownership structure and respective ownership percentage.
NAME
OWNERSHIP
PERCENTAGE
6. Has the name of the firm changed, has it been acquired or has it purchased, been acquired by , merged with or consolidated
with any firm or business in the past 5 years? (If "Yes", please provide details on your letterhead.)
7. Does any person or entity with an equity or ownership interest in the Applicant business also control, own, manage or
operate any construction business, real estate agency, real estate investment or Title Insurance carrier? (If "Yes", please
provide details on your letterhead.)
8. 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? (If "Yes", please provide details on your
letterhead.)
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Title Agents E&O Insurance Application, cont.
9. List the number of professional employees under the respective job description (if “other”, please describe).
If and individual has less than five (5) years experience in any of the professions listed below, please provide details of experience related
to the title industry on your letterhead or resume.
TITLE AGENT/
READER
ABSTRACTOR/
SEARCHER
LAWYER /
CLEARANCE
OFFICER
ESCROW AGENT/
CLOSER
OTHER (DECRIBE)
Total Number of Employees:
10. List the top three (3) Title Insurers / Underwriters with whom business is or has been placed in the past three (3) years. Include any
“Bar-related title Insurer”. All information must be complete.
Date First
Represented
Title Insurer/Underwriter
Percentage of
Total Premium
Written
11. Has any Title Insurer /Underwriter ever cancelled, changed or non-renewed your agency contract?
12. Does the applicant have fidelity coverage currently in force?
If Yes, what is the Limit provided?
13. Does the applicant have Errors & Omissions Liability Insurance currently in force?
If Yes, please provide information for the past three (3) years:
Insurance Company
Limits of Liability
Deductible
Premium
Policy Period
Please provide the retroactive Date of your expiring policy:
If you are currently insured, please send a copy of your current policy declarations Page or Certificate of Insurance taking care that
we can identify the Retroactive (prior acts) Date.
14. Gross Revenues (Annual) (if new, please estimate income)
Revenues from Prior
12 Months
Projected Revenues
for Upcoming 12
Months
Ave. # of
transactions per
month
Title Agent
Escrow Agent
Closer
Abstracter/Searcher
Witness Closer/Signing Agent
Other, please describe:
TOTAL
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Title Agents E&O Insurance Application, cont.
15. Projected Revenue By State.
State
Revenue
TOTAL:
16. Revenue Categories.
PERCENTAGE OF
TOTAL ANNUAL
GROSS REVENUE
(MUST TOTAL 100%)
CATEGORY
Agriculture/Raw Land
Residential
Commercial
Construction
Oil & Gas
Metal & Mineral
Other, please describe:
TOTAL
17. Does the Applicant use independent contractors or leased workers?
If Yes, please indicate the percentage of your business performed by independent contractors and/or leased workers in the
following functions. IF NOT APPLICABLE, PLEASE INDICATE “NONE”.
Title Agents/Readers
%
Escrow Agents/Closers
%
Abstractors/Searchers
%
Other
%
If, "Other" describe:
18. Do you request independent contractors and/or leased workers to carry Errors & Omissions Liability Insurance?
If Yes, please estimate the percentage that purchase coverage?
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Title Agents E&O Insurance Application, cont.
19. Please indicate which of the following sources you use for Title Searches.
PERECENTAGE OF
TOTAL BUSINESS
(MUST TOTAL 100%)
CATEGORY
Applicant Firm
Independent Contractor /l Leased Worker
Title Insurer/Underwriter
Other (describe)
TOTAL
COMPLETION OF QUESTIONS 20-24 REQUIRED ONLY IF APPLICANT IS PERFORMING ESCROWS/CLOSINGS/
SETTLEMENTS, IF NOT APPLICABLE, SKIP TO QUESTION # 25.
20. Who performs Applicant's escrows / closings / settlements? (Must total 100%)
% of Total
Business
CATEGORY
Applicant Firm
Independent Contractor /l Leased Worker
Title Carrier
TOTAL
21. When providing escrows/closings/settlement services, does applicant:
a. Use Software for all escrow, closing, settlement activities
b. Require written approval or funding number on all settlement or most current HUD - 1 statements prior to closing?
c. Obtain a “gap" or “date shown” search on the chain of title and any liens on property 24 hours prior to closing?
d. Perform a “post closing” title search and/or obtain original filed documents to assure filing was made?
e. Conduct all closings with Title Insurance, title commitment Title opinion or use a written disclaimer or hold Harmless
as to the condition of title?
f. Document and obtain signatures from all parties on any change/deviation to Escrow / Purchase Contracts?
g. Follow lender instructions or, if not provided, have standard written procedures for closings and escrows?
h. Conduct all closings with title insurance, title commitment Title opinion in hand, or, use a written disclaimer or hold
Harmless as to the condition of title?
22. Are the applicant's escrow agents required to have a license in any of the states in which they provide escrow services.
If "Yes", what are the applicable states in which such license is required?
23. Has every escrow agent employed by the applicant or performing services on behalf of the applicant as an independent
contractor satisfied all licensing requirements?
If "No" please explain.
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Title Agents E&O Insurance Application, cont.
24. Does the applicant have a cross checking system to guard against.
a. Incorrectly kept records of closing transactions?
b. Failure to make proper filing of documents for public record?
c. Improper calculation of tax, insurance or other finance figures?
If "Yes" to either a,
b or c, please
provide details:
25. Do you provide UCC Reports?
26. Have any principals, partners, officers or professional employees ever been the subject of reprimand or disciplinary or
criminal actions by authorities as a result of their professional activities? (If "Yes", please provide details on your
letterhead.)
27. Does any person to be insured have knowledge or information of any act, error or omissions which might reasonably be
expected to give rise to a claim against him or his predecessors in business? (If "Yes", please provide details on your
letterhead.)
28. Have any professional liability claims ever been made against any proposed insured(s)? (If "Yes", please provide details
on your letterhead.)
NOTICE TO APPLICANT-PLEASE READ CAREFULLY
The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not
bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy
be issued, and this application will be attached to and become a part of such Policy, if insured. Insurers hereby are authorized to
make any investigation and inquiry in connection with this Application as they may deem necessary.
It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted
herewith (which shall be retained on files by Insurer and which shall be deemed attached hereto, as if physically attached hereto), are
the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy.
1.
It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date of
the Policy, the applicant will notify Insurer and, at the sole discretion of Insurer, any outstanding quotations may be modified or
withdrawn.
2.
It is agreed that in the event there is any misstatement or untruth in the answers to the questions contained herein, Insurer have the
right to exclude from coverage any claim based upon, arising out or if in connection with such misstatement or untruth.
3.
Agent hereby authorizes its title insurance underwriter, FNTG, to release to the errors and omissions carrier or its broker any and all
information it may have concerning the Agency, including, but not limited to, remittance histories, claims histories/losses, and any
other information the broker/carrier might request from FNTG. Agent understands this information may be used to determine
insurability by the errors and omissions carrier(s) and also may affect the errors and omissions insurance rates.
Signed By:
Date
For purposes of creating a binding contract of insurance by this application or in determining the rights and obligations under such contract in
any court of law, the parties acknowledge that a signature reproduced by either facsimile or photocopy shall be the same force and effect as an
original signature and that the original and any such copies shall be deemed on and the same document.
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