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  • ENDORSED BY THE AMERICAN LAND TITLE ASSOCIATION

    New Application
  • NOTICE: A policy may be issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State guaranty funds are not available for your risk retention group.

    The insurance coverage for which you are applying is written on a CLAIMS MADE AND REPORTED policy. Therefore, only claims which are first made against you and reported during the policy period are covered, subject to policy terms, exclusions and conditions including the notice of claim conditions of the policy. "Claim" means any demand received by the Insured for money or services, including the service of suit or institution of arbitration proceedings against the Insured, alleging a wrongful act.

    INSTRUCTIONS: Please TYPE or PRINT clearly. Please answer ALL questions completely. If there is insufficient space to complete an answer, please continue on a separate sheet of your firm's letterhead, indicating the number of the question(s). This form must be completed, signed and currently dated by an owner, member, principal or officer of the firm applying for coverage.

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  • 12. OWNERS AND STAFF: (indicate numbers; count each person only once): 

  • a. All owners, officers and employees engaged on a full or part-time basis in one or more of the following activities: abstracting, searching, title underwriting, title opinion, escrow/closing services, commitment or policy preparation/production: *

  • c. Of the number in 12.a, how many are part-time (i.e., less than 20 hours per week)?

  • *Please provide evidence that all independent contractors maintain their own E&O insurance by attaching copies of certificates of insurance or declarations pages for each independent contractor. Coverage may be limited or excluded for any claim that relates in any way to services by an independent contractor unless the independent contractor has E&O insurance with at least $250,000 limits of liability

  • Please include revenue for each activity checked above in response to questions 13a – e.

  • 13. Please include amount of revenue for each activity checked in response to question 10.

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  • IMPORTANT: Answer questions 18, 19, and 20 only after inquiry of each owner, member, principal or officer of the Applicant. Include data on predecessor firms (see question 6).

  • If YES, complete the CLAIM INFORMATION SECTION (PAGE 8) for each claim with a total cost of $2,500 or more.

  • NOTE: Any claim arising from any wrongful act, error, omission, circumstance, fact or situation disclosed or required to be disclosed in response to questions 18, 19 and 20 above is EXCLUDED from coverage under the proposed insurance.

  • I/We hereby warrant, after inquiry of all persons identified in response to question 12.a., that the above statements and particulars are true and that l/we have not suppressed or misstated any material facts and I/we agree that this Application, including any attachments, shall be deemed to be material to the risk assumed by TIAC; shall be the basis of the contract with TIAC; and that any policy issued may be affected by any suppression or misstatement. It is understood and agreed that this Application forms a part of any policy issued by TIAC to the Applicant and shall be deemed to be attached to and form a part of the policy. It is understood and agreed that completion of this Application does not bind TIAC to issue nor the Applicant to purchase any policy.

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  • CLAIM INFORMATION SECTION

    Applicant's Instructions-Please read carefully
  • (a) This form is to be completed if the Applicant or any predecessor firm has been involved in any claim or suit which has either resulted in payments and/or defense costs totaling $2,500 or more, or if any claim is pending and it is anticipated that payments of $2,500 or more will be made.

    (b) Complete a separate form for each claim. Please copy and use this form to report any additional claims.

    (c) If space is insufficient to answer any question fully, please attach a separate sheet.

    (d) LEAVE NO BLANKS.

    (e) Please neatly print or type all answers. (f) A principal or officer of the Applicant firm must sign this page in addition to the last page of the TIAC Professional

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  • 11. Description, including assessment of liability if pending (please provide enough informaiton to allow evaluation):

  • The information submitted herein becomes a part of the Professional Liability (E&O) Insurance Application and is subject to the same representations and conditions.

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  • (Application must be signed by an owner, member, principal or officer of the Applicant firm)

  • PRIVACY BREACH AND CLIENT FUNDS PROTECTION COVERAGE SUPPLEMENTAL APPLICATION

    Applicant's Instructions - Please Read Carefully
  • (a) This form is to be completed by all Applicants.

    (b) Answer all questions and please neatly print or type all answers.

    (c) An owner, member, principal, or officer of the Applicant firm must sign this page in addition to the last page of the TIAC Professional Liability (E&O) Application.

  • The information submitted herein becomes a part of the Professional Liability (E&O) Insurance Application and is subject to the same representations and conditions.

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