Company

Company/Applicant
Contact Person
Address
City
State	ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code
Telephone
Fax
E-mail
Your comments

General

Year Established

Do professional employees have at least 3 years of real estate or title industry related work experience?

Yes No

Estimated population of your service area

0 to 200,000 200,000 to 999,999 1,000,000 Or More

Percent of your work that is residential

Percent of your work that is performed by subcontractors
Do you require subcontractors to carry E&O?	Yes No

Current Coverage

Do you have E&O currently in force?

Yes No

Name of Current Carrier
Current Limits
Expiration Date
Retroactive or Prior Acts Date

Desired Limits

Please check your desired Limit of Liability and Deductible. Choose all that apply.

Limit of Liability
$250,000 / $500,000	Yes No
$500,000 / $500,000	Yes No
$500,000 / $1,000,000	Yes No
$1,000,000 / $1,000,000	Yes No
Deductible
$1,000	Yes No
$2,500	Yes No
$5,000	Yes No
$10,000	Yes No

Revenues

Projected Annual (12 mo.) Gross Revenues Revenue Breakdown (must total 100%) Title Agent Escrow Agent/Closer Abstract/Search Grand total: 0 Witness Closer/Signing Agent Other Describe Other

Does the applicant: Use software for all escrow, closing, and settlement activities? Yes No Document & obtain signatures from all parties on any change to Escrow/Purchase Contracts? Yes No Require written contract or instructions for each closing? Yes No Require guaranteed funds prior to closing? Yes No Require work to be checked by a peer or supervisor? Yes No Use a standard closing/escrow checklist? Yes No Hold escrow funds for longer than 1 year? Yes No Conduct a closing without title insurance, title commitment or title opinion? Yes No If yes, does the applicant use written disclaimer or hold harmless as to condition of title? Yes No

Claims

Have you had claims in the past five years?

Yes No

Number of claims
Year that most recent claim was reported
Total claim amount(s) paid