INSTRUCTIONS

Please type or print clearly in ink. Answer all questions. If the answer to any question is "Not Applicable", please state "N/A". If space is insufficient to answer any question fully, attach a separate sheet. This application must be signed and dated by Applicant’s Principal, Partner or President. Older applications may have to be resigned and re-dated.

GENERAL INFORMATION
  Are you an insurance broker?
  If Yes, please provide:
 
Agency Name:    
Broker Name: Broker Email:
Broker Phone: Broker Fax:
1. Application / Company Name:
2. Contact Person and Title:
3. Physical Address:
  Please attach a listing of any additional Applicants and/or physical address of branch locations.
4. Mailing Address (list Address, City, St and Zip if different):
5. Telephone Number: 6. Fax Number:
7. E-Mail Address: 8. Web Site:
9. Applicant is:
10. Year established:
11. List all Officers and Owners and their titles:
 
Name Title Ownership Percentage Owner/Officer active in daily business
%
%
%
12. a. Total number of employees:
  b. Please provide the total number of Applicant’s active employees performing the Job Descriptions noted below along with the number of employees who have less than 3 years of real estate or title industry related work experience. Example: If Employee X is both a Title Agent and Escrow Agent, then count them for both Job Descriptions. Please include any active owners or officers who may also perform these jobs.
 
Job Descriptions Total # of Employees by Job From the total # by job, please list the # of employees with less than 3 yrs experience
Title Agent
Escrow Agent / Closer
Abstractor / Searcher
Clerical / Support Staff  
13. Are all professional employees with less than 3 years experience supervised by senior staff / officer?
14. Does Applicant have bond coverage currently in force? (check all that apply)
  Fidelity (Crime, Employee Dishonesty) Surety (Performance Bond)
15. a. Does Applicant have error and omission liability insurance currently in force?
  b. If “Yes”, please attach a current policy declarations page or a certificate of insurance for each applicable service. Be sure we can recognize the expiration date and the retroactive (or prior acts) date.
    Please Enter the Expiration Date:
    Please Enter the Prior Acts Date:
16. Please check the Applicant’s desired Limit of Liability and Deductible (choose all that apply):
 
Limit of Liability: 100,000 / 100,000
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
BUSINESS INFORMATION
17.
Gross Revenues (Annual): (If new, estimate income) Prior fiscal year (actual) Current fiscal year (estimates) Average Number of Mo. Transactions
Title Agent $ $
Escrow Agent / Closer $ $
Abstractor / Searcher $ $
Witness Closer / Signing Agent $ $
Other $ $
Totals $ $  
18. a. Does 20% or more of Applicant total revenues come from one client?
  b. If “Yes”, please list the largest client and describe their business:
    How much total revenue is received from this client?
19. What percent of Applicant’s total work is residential, agricultural or raw land (vacant lots)?
20. Has the name or structure of the Applicant ever changed, or has there been an acquisition, consolidation, merger, dissolution, reconstitution or any other change?
  If “Yes”, provide details:
  FAILURE TO DISCLOSE OWNERSHIP, NAME CHANGES, OR D/B/A’S COULD AFFECT COVERAGE IN THE EVENT OF A CLAIM.
21. Is the Applicant affiliated with any real estate development or construction company through common ownership, operation or control including any controlled business arrangements?
22. a. Does Applicant use independent contractors or leased workers?
  b. If “Yes”, are independent contractors/leased workers required to carry errors and omissions liability insurance?
  c. If “Yes”, please provide proof of coverage (declarations page or certificate of insurance).*
    *The applicant certifies that it will continue to require independent contractors or leased workers to obtain E&O insurance throughout the life of this policy or after the date of execution of this application.
23. Who performs the applicant’s title searches? Must total 100%
 
Category % of Total Business  
Applicant Firm % If applicant performs title searches, please reflect revenue in Question #17
Independent Contractor/Leased Worker % If contractor performs title searches, please complete Question #22.a. through c.
Title Underwriter/Company %  
Total 100%  
24. Does the Applicant:
  a. Verify legal description?
    If “Yes”, please state the source used to verify:
  b. Perform a title search, document and verify all requirements are met prior to issuing a title policy?
  c. Use an attorney to provide a title opinion prior to issuing title commitment?
25. List the top two Title Underwriters Applicant issues title policies for and the percentage of the Applicant’s total revenue.
 
Title Underwriters % of Applicant’s Total Revenue
ESCROWS/CLOSINGS/SETTLEMENTS   If not applicable, skip to LOSS HISTORY
 
Complete The Following Only If CONDUCTING Escrows/Closings/Settlements
26. Who performs Applicant’s escrows/closings/settlements? Must total 100%
 
Category % of Total Business  
Applicant Firm % If applicant performs title searches, please reflect revenue in Question #17
Independent Contractor/Leased Worker % If contractor performs title searches, please complete Question #22.a. through c.
Title Underwriter/Company %  
Total 100%  
27. When providing escrows/closings/settlements services, does Applicant:
  COMPLETE ONLY IF APPLICANT FIRM PERFORMS THE CLOSING OR ESCROW SERVICE
  a. Use software for all escrow, closing or 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 the 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. Document and obtain signatures from all parties on any change/deviation to Escrow or Purchase Contracts?
  f. Follow lender instructions or, if not provided, have standard written procedures for closings and escrows?
  g. 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 the title?
LOSS HISTORY
IF “YES” TO ANY OF THE FOUR FOLLOWING QUESTIONS, PLEASE COMPLETE THE CLAIMS ADDENDUM LOCATED ON THE LAST PAGE OF THE APPLICATION.
28. Has the Applicant or any prospective Insured been involved in any criminal action or litigation in the past five (5) years? If “Yes”, please provide a written narrative for each circumstance.
29. Has the Applicant or any prospective Insured been involved in or have knowledge of any inquiry, investigation, complaint or notice from any State or Federal Authority regarding the activities, procedures or practices of the Applicant or any proposed Insured? If “Yes”, please provide a written narrative for each circumstance.
30. During the past five (5) years, has any professional liability claim or suit ever been made against any Applicant or prospective Insured? If “Yes”, you must complete the attached claims addendum for each claim or suit.
31. Does the Applicant or any prospective Insured know of any circumstances, acts, errors or omissions that could result in a professional liability claim against the Applicant? If “Yes”, you must complete the attached claims addendum for each circumstance.

FOR NEW BUSINESS, IT IS AGREED THAT IF ANY OF THE RESPONSES TO QUESTIONS 28 THRU 31 ARE “YES”, ANY CLAIM OR CIRCUMSTANCE THAT COULD RESULT IN A CLAIM WILL BE EXCLUDED FROM THE PROPOSED COVERAGE

COVERAGE IS UNDERWRITTEN BY ASPEN SPECIALTY INSURANCE COMPANY, 175 CAPITAL BLVD., ROCKY HILL, CT 06067, PHONE TOLL FREE (877) 245-3510 AND OFFERED THROUGH RESSURANCE™ PURCHASING GROUP. THE PROGRAM HAS BEEN ORGANIZED AS A PURCHASING GROUP, A NOT-FOR-PROFIT CORPORATION LOCATED AND DOMICILED IN THE DISTICT OF COLUMBIA PURSUANT TO LEGISLATION ENACTED BY CONGRESS KNOWN AS THE FEDERAL LIABILITY RISK RETENTION ACT OF 1986 AS AMENDED. YOU WILL AUTOMATICALLY BECOME A MEMBER OF THE PURCHASING GROUP WHEN YOUR APPLICATION HAS BEEN APPROVED AND YOUR PAYMENT HAS BEEN RECEIVED.

BY SIGNING THIS APPLICATION BELOW, THE APPLICANT AGREES THAT AFTER INQUIRY OF ALL PROSPECTIVE INSUREDS, NO PERSON PROPOSED FOR COVERAGE IS AWARE OF ANY FACT OR CIRCUMSTANCE WHICH REASONABLY MIGHT GIVE RISE TO A FUTURE CLAIM THAT WOULD FALL WITHIN THE SCOPE OF THE PROPOSED COVERAGE.

NOTICE TO APPLICANT - PLEASE READ CAREFULLY

RECEIPT AND REVIEW OF THIS APPLICATION DOES NOT BIND THE INSURER TO PROVIDE THIS INSURANCE

IT IS AGREED BY THE APPLICANT AND THE INSURER THAT THE PARTICULARS AND STATEMENTS MADE IN THIS APPLICATION, TOGETHER WITH ALL ATTACHMENTS TO THIS APPLICATION AND ANY OTHER MATERIALS SUBMITTED TO THE INSURER (ALL OF WHICH ATTACHMENTS AND MATERIALS SHALL BE DEEMED ATTACHED TO THE POLICY AS IF PHYSICALLY ATTACHED THERETO) SHALL BE THE REPRESENTATIONS OF THE APPLICANT AND THE PROSPECTIVE INSUREDS. IT IS FURTHER AGREED BY THE APPLICANT AND THE PROSPECTIVE INSUREDS THAT THIS POLICY, IF ISSUED, IS ISSUED IN RELIANCE UPON THE TRUTH OF SUCH REPRESENTATIONS THAT ARE INCORPORATED INTO AND MADE PART OF THIS POLICY. AFTER INQUIRY OF ALL PROSPECTIVE INSUREDS, THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT REPRESENTS THAT THE STATEMENTS SET FORTH IN THIS APPLICATION AND ITS ATTACHMENTS AND OTHER MATERIALS SUBMITTED TO US ARE TRUE AND CORRECT. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER.

THE UNDERSIGNED FURTHER DECLARES THAT ANY EVENT TAKING PLACE BETWEEN THE DATE THIS APPLICATION WAS SIGNED AND THE EFFECTIVE DATE OF THE INSURANCE APPLIED FOR WHICH MAY RENDER INACCURATE, UNTRUE, OR INCOMPLETE ANY INFORMATION IN THIS APPLICATION, WILL IMMEDIATELY BE REPORTED IN WRITING TO US AND WE MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.

General Fraud Statement

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

Fraud Notices for Applicants in Specific States

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY.PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: ARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.

NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.

NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

Applicant's Name Title