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

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TA A01a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 1 of 5
May not be copied without permission.
COMP
ANY PROVIDING COVERAGE: Greenwich Insurance Company
TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE
RENEWAL APPLICATION
THIS IS A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES 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 POL
ICY PERIOD
UNLESS AN EXTENDED CLAIM REPORTING PERIOD APPLIES. DEFENSE EXP
ENSES ARE
WITHIN AND REDUCE THE LIMITS OF LIABILITY. PLEASE REVIEW THIS POLICY CAREFULLY.
1.
Applicant’s Name:
Principal Contact:
2.
Address:
City:
State:
Zip:
County:
E-mail Address:
Web Site:
Phone Number:
Fax Number:
Total gross revenues of Applicant and all insured subsidiaries for the last twelve (12) months:
$
a.
Escrow / Closing Fees:
%
b.
Searches:
%
c.
Title Insurance:
%
d.
Abstracting:
%
e.
1031 Exchanges*:
%
f.
Other (Explain):
%
*If there is any work concerning 1031 exchanges, provide full details on a separate sheet.
4.
Does the Applicant or any insured subsidiary become involved in any work concerning
oil, gas, timber or precious metals/minerals?
Yes
No
If yes, provide full details on a separate sheet.
5.
During the last twelve (12) months have there been any changes to the ownership
structure of the Applicant or did the Applicant acquire, consolidate with, merge or
dissolve any entity?
Yes
No
If yes, provide full details on a separate sheet.
TA A01a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 2 of 5
May not be copied without permission.
6.
During the last twelve (12) months has the Applicant changed the scope of their
professional services?
Yes
No
If yes, provide full details on a separate sheet.
7.
Have any claims or suits been made during the past twelve (12) months against the
Applicant, any insured subsidiary, their predecessor firms or any of the partners,
principals, directors, officers, employees or independent contractors of the Applicant or
any insured subsidiary?
Yes
No
8.
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?
Yes
No
If yes, to either 7. and/or 8. complete the claims supplement for each claim or circumstance. Please note that
this does not constitute the reporting of any claim or incident to the insurer, and any claims or incidents must
be reported in accordance with the terms and conditions of the expiring policy.
9.
Does the Applicant engage any independent contractors or outside entities to perform
professional services on behalf of your clients?
Yes
No
% of work done by IC’s
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?
Yes
No
c.
Are you required to include them as Insureds under your policy?
Yes
No
If yes, please explain:
10.
Does the Applicant ever accept email instructions concerning the distribution of funds?
Yes
No
If yes, please advise if any follow up is done to confirm the authenticity of the email:
11.
Risk Management
a.
If contracts are used, are they reviewed by legal counsel?
Yes
No
b.
Does the Applicant have written procedures to ensure compliance?
Yes
No
c.
Does the Applicant have formalized in-house training procedures?
Yes
No
d.
Does the Applicant have a business process audit policy and procedures?
Yes
No
e.
Does the Applicant have a formal Disaster Recovery Plan?
Yes
No
f.
Is Continuing Education required for all licensed employees?
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
TA A01a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 3 of 5
May not be copied without permission.
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.
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.
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.
TA A01a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 4 of 5
May not be copied without permission.
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.
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.
N
OTICE 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.
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE
TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S
ACCEPTANCE OF THE COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING
TA A01a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 5 of 5
May not be copied without permission.
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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TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS (Risk Placement Services, Inc.)

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Completed 23 November 2020

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