Fillable COMPANY PROVIDING COVERAGE: Greenwich Insurance Company Indian Harbor (Risk Placement Services, Inc.)

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COMPANY PROVIDING COVERAGE: Greenwich Insurance Company Indian Harbor (Risk Placement Services, Inc.)

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TA
A03-IR 0516
© 2016 X.L. America, Inc. All Rights Reserved. Page 1 of 4
May not be copied without permission.
COMPANY PROVIDING COVERAGE: Greenwich Insurance Company
Indian Harbor Insurance Company
INSTANT RENEWAL TITLE AGENT PROFESSIONAL LIABILITY – ERRORS
AND OMISSIONS INSURANCE APPLICATION
THIS IS A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPL
IES ONLY TO CLAIMS
FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD. TH
E CLAIM MUST BE
REPORTED IMMEDIATELY IN WRITING TO THE COMPANY DURING THE
POLICY PERIOD
UNLESS AN EXTENDED CLAIM REPORTING PERIOD APPLIES. DEFENSE
EXPENSES ARE
WITHIN AND REDUCE THE LIMITS OF LIABILITY. PLEASE REVIEW THIS POLICY CAREFULLY.
Applicant’s Name:
Principal Contact:
Address:
City:
State:
Zip:
County:
E-mail Address:
Web Site:
Phone Number:
Fax Number:
To be eligible for a binding quote, your responses to questions 1 through 4 must be “NO”. If you answered
“YES” to any of questions 1 through 4, please contact your agent.
1.
Did the Applicant’s gross revenues increase more than ten (10%) percent during the
past twelve (12) months?
No
2.
Has the Applicant purchased, acquired, been acquired by, merged with, or
consolidated with any other business in the past twelve (12) months?
No
3.
During the last twelve (12) months has the Applicant changed the scope of their
professional services?
No
TA A03-IR 0516
© 2016 X.L. America, Inc. All Rights Reserved. Page 2 of 4
May not be copied without permission.
4.
Is the Applicant, any insured subsidiary, their predecessor firms or any partner,
principal, director, officer, employee or independent contractor of the Applicant or any
insured subsidiary aware of any circumstance, act, error or omission which may result
in a claim against any of them?
No
If your responses to questions 1 through 4 were “NO”, your policy premium, terms, and
conditions will continue as expiring for another policy year.
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 for 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, electronic,
electronic impulse, facsimile, magnetic, oral, or telephonic communication or 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.
T
A A03-IR 0516
© 2016 X.L. America, Inc. All Rights Reserved. Page 3 of 4
May not be copied without permission.
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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
T
A A03-IR 0516
© 2016 X.L. America, Inc. All Rights Reserved. Page 4 of 4
May not be copied without permission.
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).
N
OTICE 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.
T
HE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO
MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.
C
OMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF THE
COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.
ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH
THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE
A PART HEREOF.
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 ninety (90) days prior to the inception date.
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COMPANY PROVIDING COVERAGE: Greenwich Insurance Company Indian Harbor (Risk Placement Services, Inc.)

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Completed 30 July 2020

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