• 1. GENERAL INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • e. Are any of the principals involved in any other business/activity other than what is shown in 1d?*
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  • g. Are employees with fewer than 3 years experience supervised by senior staff/officers?*

  • 2. SUBSIDIARIES, ACQUISITIONS, MERGERS, OR CONSOLIDATIONS

  • a. Is the applicant affiliated with any organization through common ownership, operation or control?*
  • b. During the past five years has the Applicant been engaged in any business or professional services other than the "Nature of Business" described in Question 1d above?*

  • 3. ABSTRACT SEARCH REQUESTS

  • a. Does applicant use contracts / written agreements with their clients?*
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  • d. Does applicant receive written confirmation from their client if the standard number of years required for a full title search is less than 40 years ?*
  • e. Does applicant have procedures in place to keep record of their titles searches (i.e.; screen shot of search terms and search results)?*
  • f. Does the applicant use limitation of liability clauses?*
  • If "No" is applicant willing to use limitation of liability clauses moving forward to stay current with best practices?*
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  • k. Does applicant provide title opinions for closings when title insurance is not the end product?*
  • l. Has a title company ever cancelled or nonrenewed their agency contract with you?*
  • m. If Applicant provides public notary services - do they always require signer(s) to be present?*

  • 4. CORPORATE GOVERNANCE

  • a. Does the Applicant have a process in place to handle and resolve client complaints?*

  • 5. SUBCONTRACTORS

  • a. Does the Applicant use subcontractors?*
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  • c. Does the Applicant require its subcontractors to maintain professional liability insurance?*

  • 6. FINANCIAL AND BUSINESS INFORMATION

  • a. Provide Applicants Gross Annual Revenue breakdown below:
    (If no revenue in the last 12 months, provide estimate for next 12 months)

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  • d. Do you anticipate any material changes to the nature of the Applicant’s business in the next 12 months?*

  • The total in questions 6b and 6c must each equal 100% before you can proceed.

  • 7. LIMIT / DEDUCTIBLE OPTIONS

  • Please select the Limit & Deductible options you would like to have quoted (can select up to 3 options):
    *Some restrictions may apply based on underwriting criteria

  • Select Limit Option(s)**
  • Select Deductible Option(s)**

  • 8. CURRENT / PRIOR INSURANCE

  • a. Does the Applicant currently have an Errors & Omissions Insurance policy?*
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  • b. Has any Errors & Omissions or Professional Liability Insurance issued to the Applicant ever been declined, cancelled, or non-renewed?*

  • 9. CLAIMS EXPERIENCE

  • a. Do any principals, directors, officers, partners, employees, or independent contractors of the Applicant have knowledge or information of any actual or alleged acts, errors, omissions, offenses or circumstances which might reasonably be expected to give rise to a claim against the Applicant?*
  • b. During the past five (5) years, has the Applicant, or any of its predecessors in business, subsidiaries, or affiliates, or any of the principals, directors, officers, partners, employees or independent contractors ever been under investigation by any professional/regulatory body or been subject to disciplinary action as a result of professionalactivities?*
  • c. During the past five (5) years, have any suits or claims been brought against the Applicant, any of its predecessors in business, subsidiaries, or affiliates, or any of the principals, directors, officers or employees?*

  • If the answer to 9a, 9b, or 9c above is “Yes,” complete the Supplemental Claims Questionnaire at the end of this application for each Claim, Notice, or Circumstance. We also will require currently valued loss runs dating back to the earliest claim indicated in 9c.

  • 10. ASSOCIATIONS

  • Are you currently a member of any land title association?*

  • SIGNATURES

  • l/We hereby warrant, that the statements and particulars provided in this Application are true and that l/we have not suppressed or misstated any material facts and that l/we agree that this Application shall be the basis of the contract with the Company and that the coverage, if written, may be affected by any suppression or misstatement. It is understood and agreed that this Application forms a part of any Policy issued by the Company 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 the Company to issue nor the Applicant to purchase the insurance.

  • Date*
     - -

  • PRODUCER SUBMITTING ON BEHALF OF THE INSURED

  • Format: (000) 000-0000.
  • Do you give Fox Point Programs authorization to broker this account if not eligible for our in-house program?*

  • Date of the alleged act, error, or omission*
     / /
  • Is this a*
  • Is this matter settled?*
  • d. Was the Applicant insured under a Professional Liability policy at the time of the incident?*

  • THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.

    THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY. SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIALTOTHE ACCEPTANCE OFTHE RISK OR HAZARD ASSUMED.

  • Date*
     / /
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