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E-mail Submit
Gotham Insurance Company
Southwest Marine & General Insurance Company
Submission Contact:
Toll Free #: 1-800-749-7326
E-mail address: treiberEandO@ajg.com
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, OWNERS, OR OFFICER NOT EARLIER THAN 45 DAYS BEFORE THE
PROPOSED EFFECTIVE DATE OF COVERAGE.
1. Applicant:
Address:
Zip Code: City:
Phone Number:
E-Mail Address:
Who is your FNTG sales manager or rep?
2. Are there other office locations?
Fax Number:
Web Address:
State: 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.)

9. List the number of professional employees under the respective job description ( If “Other”, please describe ).
If any 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 Escrow Agent/Closer Lawyer/Clearance Officer Other (Describe)
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.
Title Insurer/Underwriter
Date First
Represented
Percentage of Total
Premium Written
11. Has any Title Insurer /Underwriter ever cancelled, changed or non-renewed your agency contract?
If "Yes", please provide details on your letterhead.
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 details on your letterhead.
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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15. Projected Revenue By State:
State Revenue
16. Revenue Categories:
Category
Percentage Of Total
Annual Gross Revenue
(Must Total 100%)
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”, please 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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19. Please indicate which of the following sources you use for Title Searches.
Category
Percentage Of Total
Annual Gross Revenue
(Must Total 100%)
Applicant Firm
Independent Contractor /Leased Worker
Title Insurer/Underwriter
Other (describe)
TOTAL
COMPLETION OF QUESTIONS 20-24 REQUIRED ONLY IF APPLICANT IS PERFORMING ESCROWS/CLOSINGS/SETTLEMENTS. IF NOT, PLEASE
ENTER N/A FOR QUESTIONS 20-24 AND PROCEED TO QUESTION # 25.
20. Who performs Applicant's escrows / closings / settlements? (Must total 100%)
Category
% of Total
Business
Applicant Firm
Independent Contractor /Leased Worker
Title Carrier
TOTAL
21. When providing escrows/closings/settlement services, does applicant: (Please explain any "No" Answers on your letterhead.) 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?
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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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 "No" to either a, b or c, please provide details:
25. Do you perform advice related to 1031 exchanges? (If yes, please provide details on your letterhead)
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 omission which might reasonably be
expected to give rise to a claim against him or his predecessor in business that has not been reported to your respective
Errors and Omissions Insurance carrier? (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 as well as a minimum of five (5) years currently valued loss runs from your previous carriers)
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 has 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.
Signature
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 one and the same document.
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