Are you an insurance broker?
  If Yes, please provide:
 
Agency Name:    
Broker Name: Broker Email:
Broker Phone: Broker Fax:

  Company / Applicant:     
  Contact Person:
  Address:
  City: State: Zip:
  Phone:
  Fax:
  Email:
1. Do you have E&O currently in force?
 
If Yes, please complete:
Name of Current Carier: Expiration Date: Expiring Premium:
Current Limits: Retroactive or Prior Acts Date:    
2. Please check your desired Limit of Liability and Deductible (choose all that apply):
 
Limit of Liability: 250,000 / 250,000
500,000 / 500,000
500,000 / 1,000,000
1,000,000 / 1,000,000
1,000,000 / 2,000,000
Deductible: 1,000
2,500
5,000
10,000
3. Projected Annual (12 mo.) Gross Revenues:
4. Please check the services that are provided (choose all that apply):
 
Title Agent
Closing, Escrow or Settlement Agent
Other Services (doc prep, courtesy filing, etc.)
Abstractor, Searcher or Title Examiner
Witness Closing or Signing Agent
5. Revenue Breakdown (must total 100%):
 
% Title Agent
% Escrow Agent/Closer
% Abstract/Search
% Witness Closer/Signing Agent
% Other:
6. Percent of your work is residential: %
7. Percent of work performed by subcontractors: %
 
If Yes, are subcontractors required to carry E&O?
8. Have you had claims in the past five years?
 
If Yes, please complete: Number of Claims:
Year that Most Recent Claim was Reported:
Total Claim Amount(s) Paid: