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

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TA A02 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 1 of 4
May not be copied without permission.
TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE
SUPPLEMENTAL CLAIM INFORMATION FORM
Applicant’s Instructions:
1. Compl
ete one form for each claim or incident.
2. If
space is insufficient to answer any question fully, use the reverse side of this page or attach a
separate sheet. Answer all questions completely.
(PLEA
SE TYPE OR PRINT)
1.
Applicant’s Name:
2.
Additional Defendants:
3.
Full Name of Claimant:
4.
To what Insurance Company did you report this claim or incident?
a.
Date reported to Insurance Company:
b.
Date you first received notice:
c.
Date of alleged error:
5.
Present status of claim (check one):
In Suit
Open Incident
a.
If Closed, total damages paid including Claim Expense and Deductible:
$
Indicate whether:
Court Judgment
or
Out of Court Settlement
TA A02 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 2 of 4
May not be copied without permission.
b.
If Pending:
Amount asked in Summons:
$
Claimant’s settlement demand:
$
Defendant’s offer for settlement:
$
Insurer’s loss reserve*:
$
Deductible:
$
*Unknown is unacceptable. Please contact insurance company or defense attorney for a good faith
estimate.
6.
Description of Claim: (Provide enough information to allow evaluation and attach a separate page if
additional space is required).
a.
Alleged act, error or omission upon which Claimant bases claim:
b.
Description of case and events:
c.
Description of the type and extent of injury or damage allegedly sustained:
7.
Have you changed policies or procedures as a result of this claim that will reduce the
possibility of a similar occurrence?
Yes
No
If yes, please describe:
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.
TA A02 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 3 of 4
May not be copied without permission.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
N
OTICE 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.
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.
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.
TA A02 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 4 of 4
May not be copied without permission.
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.
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.
N
OTICE 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.
Applicant:
Title:
Applicant’s Signature:
Date:
Agent/Broker Name:
(Must be signed by an authorized representative who is an active owner, partner, or senior executive officer of your firm.
Application must be signed within thirty (30) days of the policy inception date).
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TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS (Risk Placement Services, Inc.)

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Completed 30 July 2020

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