Fillable Title Escrow Application

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Title Escrow Application

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The Title Escrow Application form is 4 pages long and contains:

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  • 34 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
TITLE, ESCROW & CLOSING SERVICES SUPPLEMENTAL APPLICATION
If additional space is required for any answer, please attach a separate sheet.
1. Full Name of Applicant:
2. Is the Applicant affiliated with any organization through any common ownership, operation or control, Yes No
including any controlled business arrangement, including but not limited to a law firm, real estate
agency, construction firm, real estate investment or development company, mortgage or financial
institution, or title insurance company?
If Yes, provide details on attachment indicating names and ownership percentage.
3.
Percentage
Estimate percentage of business as: Title Agent
Closing/Escrow Agent
Title Abstracter/Searcher
TOTAL 100%
Estimate percentage of gross revenues from: Residential
Commercial
Land Raw or Agricultural
Residential Construction
Commercial Construction
Oil & Gas
Metal & Mineral
1031 Exchange
Aircraft
Other (describe):
TOTAL 100%
Who performs the Applicant’s title searches: Applicant Firm
Independent Contractor*
Title Underwriter/Company
TOTAL 100%
Who performs the Applicant’s
closings/escrows:
Applicant Firm
Independent Contractor*
Title Underwriter/Company
TOTAL 100%
*If independent contractor is used, provide an attachment with the names of the
independent contractors and their professional liability insurers.
4. List states and counties where the Applicant conducts title business:
____________________________________
___________________________________________________________________________________________
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
5. List title insurance companies (DO NOT ABBREVIATE NAMES) the Applicant represents and percentage of total premium
written:
Companies
%
Percentage
%
%
TOTAL 100%
6. Has any title company ever cancelled or non-renewed their agency contract with the Applicant? Yes No
If Yes, provide on attachment the names of the title companies and the reason stated for the
cancellation or non-renewal.
7. When providing closing/escrow services does the Applicant:
(a) Perform closing and/or escrow services according to written instructions only? Yes No
(b) Internally audit escrow files prior to closing? Yes No
(c) Have a regular audit conducted by an independent CPA firm? Yes No
(d) Require a cashier’s check or “good funds” at or near escrow closings? Yes No
(e) Document and obtain signatures from all parties when making changes or deviating from
the original escrow contract? Yes No
(h) Ever close without title insurance, a title insurance commitment or a title opinion? Yes No
If Yes, does the Applicant use a written disclaimer or waiver as to condition of title? Yes No
(g) Hold escrow funds for more than one year? Yes No
If Yes, under what circumstances?
(h) Balance escrow accounts monthly or more frequently? Yes No
If not how often are escrow accounts balanced?
(i) Perform or handle any tax-deferred real estate exchanges? Yes No
If Yes, how many per year?
If Yes, are the Applicant’s services limited to the duties of an escrow/closing agent? Yes No
8. (a) Total number of closed escrows: Past 12 months: ________ Next 12 months:
(b) Value of: Largest escrow: $
Average escrow: $
9. Has any principal, director, officer and/or employee of the applicant been investigated or Yes No
convicted of a felony?
If Yes, attach details.
10. Does the Applicant carry any of the following types of insurance?
Attach Declarations or Certificate for any Yes answers.
(a) Employee Dishonesty/Fidelity Bond? Yes No
If Yes, provide Insurer: _______________________________ Limits:
(b) General Liability? Yes No
________________
(c) E&O for any other professional services performed by the Applicant or any affiliate? Yes No
Page 3 of 4
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND
WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material
thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming 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 insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
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 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 NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim
for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a 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 a 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 the person to criminal and civil penalties.
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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any
material facts.
Page 4 of 4
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of
any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon
such changes at our sole discretion.
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 of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Title Escrow Application

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Completed 2 July 2020

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