New Application

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.

1. Name of Applicant/Firm*

First NameMiddle Name (Optional)Last Name
Name of Firm (include all firm names, trading names or DBA's under which Applicant operates):*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Email Address:*
example@example.com
Website:
2. List complete addresses of ANY ADDITIONAL OFFICES below. If NONE, check here:

NONE
List complete addresses of Additional Offices:
3. Applicant operates as a:

Sole ProprietorCorporationPartnershipOther
Other:
4. Please upload a sample of your firm’s letterhead to this application. Please explain any discrepancies between your letterhead and your answer to question 1 below.

Cancelof
Please explain any discrepancies between your letterhead and your answer to question 1 below, if applicable.

11. If the Applicant's activities include acting as a title agent, list the title insurer(s) with whom the firm has agency contracts and the approximate percent of title insurance premium written with each insurer:
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: Type here*
b. Below, state the name, activities and years of title industry experience for each individual in 12.a*
c. Of the number in 12.a, how many are part-time (i.e., less than 20 hours per week)?Type here
d. Are independent contractors hired to search titles, perform closings, or provide other services?*

YESNO
e. If YES to 12.d, do independent contractors maintain their own E&O insurance? *

YESNO
f. What percent of the Applicant’s business is performed by independent contractors?
(i) Describe service(s) provided:
*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.

GROSS REVENUE: Show all revenue, fees and commissions before deduction of expenses.*

	Past Fiscal Year Ending	Next 12 Months (Estimated)
a. Title Agency Commissions (NOT premiums)
b. Abstracting / Searching Fees
c. Escrow / Closing Fees
d. Other Services (please describe service and revenue from each service on a separate sheet)
e. Total gross revenue from all sources

14. Is the Applicant controlled by or owned by or associated with, or does the Applicant control or own, any other firm or business?

YESNO
If YES, please explain below:
15. Is the Applicant (including any owner, partner, member, director, officer or employee), any subsidiary, parent or other related or affiliated organization engaged in: title underwriting as an insurer; real estate brokerage or sales; real estate development or construction; real estate lending; the formation, management or organization of group investments/syndications (including limited partnerships, general partnerships, real estate investment trusts or corporations); the practice of law or any business enterprise or professional practice OTHER THAN title agency, abstracting/searching or escrow/closing? If YES, please explain in the space below.*

YESNO
If YES, please explain below.
16. Is professional liability (E&O) insurance purchased for activities other than title agency, abstracting, escrow agency and closings (such as real estate agents E&O, attorneys E&O)?*

YESNO
If YES, please indicate the type, limit of liability per claim, insurance company and current expiration date.

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).
17. Have any claims been made during the past six (6) years against the Applicant or any person identified in response to question 12?*

YESNO
If YES, did any of the claims, whether insured or not, (1) result in payment and/or defense costs totaling $2,500 or more, or (2) is it anticipated that payments and/or expenses will total $2,500 or more?*

YESNO
If YES, complete the CLAIM INFORMATION SECTION (PAGE 8) for each claim with a total cost of $2,500 or more.
18. Is the Applicant aware of any wrongful act, error, omission or any other circumstance which might reasonably be expected to be the basis of a claim or suit against the Applicant or any person identified in response to question 11?*

YESNO
If YES, describe the circumstance below giving the date, client or title underwriter, the tract of land and a description of the potential claim or suit.
19. Has the Applicant or any person listed in question 12 had any agency agreement terminated, professional license revoked or suspended, or been formally reprimanded or subject to disciplinary action?*

YESNO
If YES, please explain below:
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.

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
1. Name of Applicant:

First NameMiddle Name (Optional)Last Name
2. Full name of individual involved in the claim:
3. Full name of claimant(s):
4. Date of alleged error:

MonthDayYear
5. Date of claim:

MonthDayYear
6. Was there litigation or arbitration?

YESNO
7. Name of E&O insurer, if any:
8. Present status of claim:

CLOSEDPENDINGIN SUITIN ARBITRATION

9. If CLOSED:

10. If PENDING:

	Losses
Amount asked in suit:
Insurer's loss reserve:
As of date of application: Total Loss paid

	Expenses
Claimant's settlement demand:
Defendant's offer for settlement:
Insurer's expense reserve:
Total Expense Paid:

11. Description, including assessment of liability if pending (please provide enough informaiton to allow evaluation):
a. Description of case and events:
b. Allegation(s) upon which claimant bases claim:
12. Explain what action(s) have been taken to prevent a recurrence or similar claim:
The information submitted herein becomes a part of the Professional Liability (E&O) Insurance Application and is subject to the same representations and conditions.
Signature of Applicant

Clear
Date

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

ENDORSED BY THE AMERICAN LAND TITLE ASSOCIATION

CLAIM INFORMATION SECTION

PRIVACY BREACH AND CLIENT FUNDS PROTECTION COVERAGE SUPPLEMENTAL APPLICATION