Fillable ADDENDUM TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND (Risk Placement Services, Inc.)

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ADDENDUM TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND (Risk Placement Services, Inc.)

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TA XL 04/15 Page 1
TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE
ADDENDUM
1.
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?
Yes
No
If yes, please explain:
2.
Has the Applicant ever performed any title services on properties located outside of the
United States?
Yes
No
3.
Is the Applicant licensed as required by the state they do business in?
Yes
No
4.
Do your two largest clients make up more than fifty percent (50%) of your business?
No
If yes, what percentage of your gross annual revenues comes from each of these
clients and in what business or industry are these clients engaged?
5.
During the past two (2) years, have you handled disbursement of funds as
construction progressed, or have you handled any periodic disbursement type
escrows?
No
If yes, please provide explanation including percentage of gross revenue emanating
from these clients:
6.
Does the Applicant engage any independent contractors or outside entities to perform
professional services on behalf of your clients?
No
If yes,
a.
Please list each individual/entity and describe the services performed:
b.
Do you require them to maintain their own errors and omissions insurance?
No
c.
Are you required to include them as Insured’s under your policy?
No
If yes, please explain:
7.
Does the Applicant ever accept email instructions concerning distribution of funds?
No
a. If yes, please advice if any follow up is done to confirm the authenticity of the email.
____________________________________________________________________________________
8. If contracts are used. Are they reviewed by legal counsel? Yes No
9. Does the Applicant have written procedures to ensure compliance? Yes No
10. Does the Applicant have formalized in-house training procedures? Yes No
TA XL 04/15 Page 2
11. Does the Applicant have a business process audit policy and procedures? Yes No
12. Does the Applicant have a formal Disaster Recovery Plan? Yes No
APPLICANT FRAUD WARNINGS
NOTICE TO ARKANSAS 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 Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: 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 of the third degree.
NOTICE TO KANSAS APPLICANTS: A "fraudulent insurance act" means an act committed by any person
who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or
belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written
statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for
personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for
commercial or personal insurance which such person knows to contain materially false information concerning
any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto.
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 denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly or willfully 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 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.
TA XL 04/15 Page 3
NOTICE TO 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 CIVIL FINES AND CRIMINAL PENALTIES.
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 PUERTO RICO APPLICANTS: Any person who knowingly and with the intention of
defrauding presents false information in an insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than
one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned
for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties.
Should aggravating circumstances [be] present, the penalty thus established may be increased to a
maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum
of two (2) years.
NOTICE TO RHODE ISLAND 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 TENNESSEE 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.
NOTICE TO 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.
NOTICE TO WASHINGTON 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.
NOTICE TO WEST VIRGINIA 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 ALL OTHER STATES: Any person who knowingly and willfully presents false information in an
application for insurance may be guilty of insurance fraud and subject to fines and confinement in prison. (In
Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may
subject the person to penalties).
TA XL 04/15 Page 4
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.
Applicant:
Title:
Applicant’s Signature:
Date:
Agent/Broker Name:
This application must be signed and dated by an owner, partner or officer of the Applicant Company
within sixty (60) days prior to the inception date.
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ADDENDUM TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND (Risk Placement Services, Inc.)

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Completed 30 July 2020

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