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

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TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 1 of 7
May not be copied without permission.
COMP
ANY PROVIDING COVERAGE: Greenwich Insurance Company
TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE
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 EXPENSES 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:
3.
Yes
No
4.
Applicant is:
Sole Proprietor
Partnership
Corporation
5.
Date Established:
/ / (Month/Day/Year)
6.
by, merged with, or consolidated with any other firm or business in the last five (5)
Yes
No
TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 2 of 7
May not be copied without permission.
7.
ownership interest in a financial institution, mortgage company, real estate
Yes
No
8.
profession other than title agent, escrow agent, abstractor, etc. or is any other type of
Yes
No
9.
Has the Applicant ever performed any title services on properties located outside of
the United States?
Yes
No
10.
Is the Applicant licensed as required by the state(s) they do business in?
Yes
No
11. Current staff (including owners). Please list the names of staff, other than clerical, and assign activity codes and
years of experience:
Activity Codes:
Owner/Partner/Officer:
O
Title Agent:
T
Closing Agent:
C
Abstractor/Searcher:
A
Escrow Agent:
E
Name of Staff
Activity Code
Licensed (Yes or No)
Years of Experience
12.
Do your two largest clients make up more than fifty percent (50%) of your business?
Yes
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?
13.
Title Activities
Gross Revenue
Last twelve (12 Months)
a.
Escrow Services / Closing Services:
$
b.
Title Agent Commissions:
$
c.
Abstracting:
$
d.
Search Fees:
$
e.
Other (Describe):
$
Total Gross Revenue:
$
TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 3 of 7
May not be copied without permission.
14.
Real Property Categories:
a. What is the approximate breakdown of your gross revenue for the last twelve (12) months for the following
categories or real estate?
(1)
Residential
%
(2)
Commercial / Industrial
%
(3)
Agricultural
%
(4)
Oil / Gas
%
(5)
Precious Metals / Minerals / Timber (i.e. coal, gravel, etc.)
%
(6)
Other (please describe):
%
Total
% (Must equal 100 %)
b.
Does the Applicant perform 1031 tax deferred exchange services?
Yes
No
(1)
As Escrow / Closing Agent only? %
Yes
No
(2)
As Intermediary / Accommodator? %
Yes
No
15.
During the past two (2) years, have you handled disbursement of funds as
construction progressed, or have you handled any periodic disbursement type
escrows?
Yes
No
If yes, please provide explanation including percentage of gross revenue emanating
from these clients:
16.
Has the firm, any subsidiary, or any employee or any other person or entity who
provide professional services on behalf of the Applicant had any state, federal or other
regulatory agency file an action of any type (including but not limited to sanctions,
fines, reprimands, suspensions or license revocation) brought against them at any
time?
Yes
No
If yes, please provide in detail:
17.
Have any claims or suits been made during the past five (5) years against the
Applicant, its predecessor firm or any of the officers or employees of the firm?
Yes
No
If yes, please complete the claims supplement and provide prior insurance company
five (5) year loss runs.
18.
Is the Applicant, its predecessor firms or any officer or employee of the firm aware of
any circumstance, act, error or omission which may result in a claim against them?
Yes
No
If yes, please attach a statement with specific details:
TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 4 of 7
May not be copied without permission.
19.
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
20.
Does the Applicant engage any independent contractors (IC) or outside entities to
perform professional services on behalf of your clients?
% of work done by IC’s
Yes
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?
Yes
No
c.
Are you required to include them as Insureds under your policy?
Yes
No
If yes, please explain:
21.
Does the Applicant ever accept email instructions concerning distribution of funds?
Yes
No
If yes, please advise if any follow up is done to confirm the authenticity of the email.
22.
a.
Prior coverage – list all title agents professional liability insurance carried during the past five (5) years.
If none, state “None”.
Insurance Company
Policy Period
Liability Limit
Deductible
Premium
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
b.
Have you been continuously insured for ten years or more?
Yes
No
If no, please indicate the date on which you first purchased continuous Errors and Omissions Coverage:
/ / (Month/Day/Year)
23.
Has any application for title agents errors and omissions insurance on behalf of the
Applicant or any predecessor firm been declined, or has any policy been cancelled or
nonrenewed? (NOT APPLICABLE IN MISSOURI)
Yes
No
If yes, explain, including specific reason for cancellation or nonrenewal:
TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 5 of 7
May not be copied without permission.
24.
Coverage Desired:
a.
Limit:
$250,000 / $250,000
b.
Deductible:
$2,500
Which will apply each
and every claim
during the Policy
Period.
$500,000 / $500,000
$5,000
$500,000 / $1,000,000
$10,000
$1,000,000 / $1,000,000
$15,000
$1,000,000 / $2,000,000
$25,000
25.
Would you like a quotation so that your deductible does not apply to defense costs
(First Dollar Defense)?
Yes
No
APP
LICANT FRAUD WARNINGS
NOT
ICE 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.
NOTIC
E 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.
NOT
ICE 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.
NOT
ICE 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.
NOT
ICE 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.
TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 6 of 7
May not be copied without permission.
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.
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.
TA A00a 0815 © 2015 X.L. America, Inc. All Rights Reserved. Page 7 of 7
May not be copied without permission.
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).
NOTI
CE 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
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 sixty (60) 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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