Errors & Omissions Insurance for Title, Escrow Agents and Abstractors. Endorsed by the American Land Title Association

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1 Errrs & Omissins Insurance fr Title, Escrw Agents and Abstractrs Endrsed by the American Land Title Assciatin The Insurance Cmpany: Title Industry Assurance Cmpany, a Risk Retentin Grup TIAC issued its first plicy in Under the 1986 amendments t the Liability Risk retentin act f 1981, a risk retentin grup is a special purpse insurance cmpany wned slely by its plicyhlders, which may write nly liability insurance-including E & O cverage. Under the act, TIAC is charted and licensed in Vermnt fr the purpse f issuing title agents and abstractrs E & O insurance natinwide Limits Available: Up t $100,000 per claim/ $2,000,000 aggregate Deductibles $2,500 t$ $50, r mre Cverage extends t independent cntractrs Optinal: Claim Expenses in additin t the limit f Liability Optinal: Annual Aggregate deductible cap. Optinal: First Dllar Defense This is nt a Binder f Insurance. All Applicatins must be apprved by the Insurance cmpany This dcument has been prepared fr illustrative purpses nly. In all situatins the plicy will gvern the terms and cnditins f the insurance cverage that is prvided. The Herbert H. Landy Insurance Agency has specialized in prviding prfessinals with Malpractice Insurance fr mre than 50 years Member f the Prfessinal Liability Underwriting Sciety 75 Secnd Ave, Suite 410, Needham, MA Tel: Visit ur web

2 Title Industry Assurance Cmpany Abstracters, Title Insurance Risk Retentin Grup Agents & Escrw Agents 7501 Wiscnsin Avenue, Suite 1500 Prfessinal Liability (E&O) Bethesda, MD Insurance FAX: 800-TIAC-FAX NEW APPLICATION ENDORSED BY THE AMERICAN LAND TITLE ASSOCIATION NOTICE: A plicy may be issued by yur risk retentin grup. Yur risk retentin grup may nt be subject t all f the insurance laws and regulatins f yur state. State guaranty funds are nt available fr yur risk retentin grup. The insurance cverage fr which yu are applying is written n a CLAIMS MADE AND REPORTED plicy. Therefre, nly claims which are first made against yu and reprted during the plicy perid are cvered, subject t plicy terms, exclusins and cnditins including the ntice f claim cnditins f the plicy. "Claim" means any demand received by the Insured fr mney r services, including the service f suit r institutin f arbitratin prceedings against the Insured, alleging a wrngful act. INSTRUCTIONS: Please type r PRINT CLEARLY. Please answer all questins cmpletely. If there is insufficient space t cmplete an answer, please cntinue n a separate sheet f yur firm's letterhead, indicating the number f the questin(s). This frm must be cmpleted, signed and currently dated by a principal f the firm applying fr cverage. 1. Name f Applicant/Firm (include all firm names, trading names r DBA's under which applicant perates): Address:* City: Cunty: State: Zip Cde: Phne: address: (REQUIRED) Fax: *List cmplete addresses f ANY ADDITIONAL OFFICES n a separate sheet. if NONE, check here:.. 2. Applicant perates as a: Sle Prprietr Crpratin Partnership Other: NONE 3. Please attach a sample f yur firm s letterhead t this applicatin. Please explain any discrepancies between yur letterhead and yur answer t questin 1 n a separate sheet f paper. 4. Year firm established: 5. Has the name f the applicant ever changed, r has there been any acquisitin, cnslidatin, disslutin, merger r change in business rganizatin? YES NO If YES, please prvide full particulars n a separate sheet, listing each firm named in chrnlgical rder. 6. List all states where applicant perates: 7. Have all applicable state licensing requirements been met?... YES NO 8. Is the applicant a member in gd standing f the American Land Title Assciatin?... YES NO 9. Applicant s business activities include: Abstracter Title Agent Escrw/Clsing Other: Please include revenue fr each activity checked abve in respnse t questins 12a e. 10. If the applicant's activities include acting as a title agent, list the title insurer(s) with whm the firm has agency cntracts and the apprximate percent f title insurance premium written with each insurer: TTLE INSURER PERCENT OF PREMIUM TIAC-2 (09/2010 Ed.) Page 1 f 4

3 11. OWNERS AND STAFF: (indicate numbers; cunt each persn nly nce): a. All wners, fficers and emplyees engaged n a full r part-time basis in ne r mre f the fllwing activities: abstracting, searching, title underwriting, title pinin, escrw/clsing services, cmmitment r plicy preparatin/prductin:. b. On a separate sheet, state the name, activities and years f title industry experience fr each individual in 11.a c. Of the number in 11.a, hw many are part-time (i.e., less than 20 hurs per week)?... d. Are independent cntractrs hired t search titles, perfrm clsings, r prvide ther services? YES NO e. If YES t 11.d, d independent cntractrs maintain their wn E&O insurance? *. YES NO f. What percent f the applicant s business is perfrmed by independent cntractrs?... % (i) Describe service(s) prvided: *Please prvide evidence that all independent cntractrs maintain their wn E&O insurance by attaching cpies f certificates f insurance r declaratins pages fr each independent cntractr. Cverage may be limited r excluded fr any claim that relates in any way t services by an independent cntractr unless the independent cntractr has E&O insurance with at least $250,000 limits f liability. 12. Please include amunt f revenue fr each activity checked in respnse t questin 9. GROSS REVENUE: shw all revenue, fees and cmmissins befre deductin f expenses. Past fiscal year ending / / a. Title Agency Cmmissins (NOT premiums) $ $ b. Abstracting / Searching Fees $ $ c. Escrw / Clsing Fees $ $ d. Other Services (please describe service and revenue frm each service n a separate sheet) $ $ e. Ttal grss revenue frm all surces $ $ Next 12 mnths (Estimated) 13. Is the applicant cntrlled by r wned by r assciated with, r des the applicant cntrl r wn, any ther firm r business? If YES, please explain n a separate sheet... YES NO 14. Is the applicant including any wner, partner, member, r emplyee, any subsidiary, parent r ther related r affiliated rganizatin engaged in: title underwriting as an insurer, title agency, abstracting r escrw/clsing, real estate brkerage r sales, real estate develpment r cnstructin, real estate lending, the frmatin, management r rganizatin f grup investments/syndicatins (including limited partnerships, general partnerships, real estate investment trusts r crpratins), the practice f law r any business enterprise r prfessinal practice ther than the applicant? YES NO (If YES, please explain n a separate sheet. Include name(s), a descriptin f services perfrmed, prperty values invlved and fees received.) 15. Are any principals, wners, partners, fficers, directrs r prfessinal emplyees f the applicant persnally engaged in any activities described in questin 14? YES NO If YES, please explain n a separate sheet, identifying the individual, the activity and any relatinships r transactins between the activity and the applicant. 16. Is prfessinal liability (E&O) insurance purchased fr activities ther than title agency, abstracting, escrw agency and clsings (such as real estate agents E&O, attrneys E&O)?... YES NO If YES, please indicate the type, limit f liability per claim, insurance cmpany and current expiratin date. TYPE OF COVERAGE LIMIT OF LIABILITY INSURANCE COMPANY EXPIRATION DATE TIAC-2 (09/2010 Ed.) Page 2 f 4

4 IMPORTANT: Answer questins 17, 18, and 19 nly after inquiry f each principal, wner, partner, member, fficer, directr and emplyee f the applicant. Include data n predecessr firms (see questin 5). 17. Have any claims been made during the past six (6) years against the applicant r any persn identified in respnse t questin 11? YES NO If YES, did any f the claims, whether insured r nt, (1) result in payment and/r defense csts ttaling $2,500 r mre, r (2) is it anticipated that payments and/r expenses will ttal $2,500 r mre?... YES NO If YES, cmplete the CLAIM INFORMATION SECTION fr each claim with a ttal cst f $2,500 r mre. 18. Is the applicant aware f any wrngful act, errr, missin r any ther circumstance which might reasnably be expected t be the basis f a claim r suit against the applicant r any persn identified in respnse t questin 11? If YES, describe the circumstance n a separate sheet giving the date, client r title underwriter, the tract f land and a descriptin f the ptential claim r suit YES NO 19. Has the applicant r any persn listed in questin 11 had any agency agreement terminated, prfessinal license revked r suspended, r been frmally reprimanded r subject t disciplinary actin? If YES, please explain n a separate sheet YES NO NOTE: Any claim arising frm any wrngful act, errr, missin, circumstance, fact r situatin disclsed r required t be disclsed in respnse t questins 17, 18 and 19 abve is EXCLUDED frm cverage under the prpsed insurance. 20. Please cmplete the fllwing fr the applicant and any predecessr firm(s) with respect t prfessinal liability (E&O) insurance fr the past six (6) years. If currently insured, please attach a cpy f the Declaratins page frm yur plicy that shws yur retractive cverage date. If n past cverage, indicate NONE. NONE Plicy Perid (MM/DD/YY t MM/DD/YY) Prir Acts Cvered (YES/NO) Activities Cvered: TO-title pinins TA-title agency AB-abstracting E/C-escrw/clsing E&O Insurance Cmpany (nt agent) Limit f Liability (per claim) Deductible (per claim) 21. Limits f liability (each claim/annual aggregate) requested: $250,000/$500,000 $500,000/$1,000,000 $1,000,000/$2,000,000 $250,000/$250,000 $500,000/$500,000 $1,000,000/$1,000,000 Deductible (each claim) requested: $2,500 $5,000 $10,000 $25,000 $50,000 Annual Premium I/We hereby warrant, after inquiry f all persns identified in respnse t questin 11.a., that the abve statements and particulars are true and that l/we have nt suppressed r misstated any material facts and I/we agree that this applicatin shall be the basis f the cntract with the Cmpany and that cverage, if written, may be affected by any suppressin r misstatement. It is understd and agreed that this applicatin frms a part f any plicy issued by the Cmpany t the applicant and shall be deemed t be attached t and frm a part f the Plicy. It is understd and agreed that cmpletin f this applicatin des nt bind the Cmpany t issue nr the applicant t purchase the insurance. Name and Title f Applicant (please print) Signature f Applicant Date (Applicatin must be signed by a principal r wner f the Applicant firm) Please mail, fax, r yur cmpleted and signed applicatin and any ther required materials t: Title Industry Assurance Cmpany 7501 Wiscnsin Avenue, Suite 1500 Bethesda, MD FAX 800-TIAC-FAX TIAC-2 (09/2010 Ed.) Page 3 f 4

5 CLAIM INFORMATION SECTION Applicant's Instructins Please read carefully (a) This frm is t be cmpleted if the applicant r any predecessr firm has been invlved in any claim r suit which has either resulted in payments and/r defense csts ttaling $2,500 r mre, r if any claim is pending and it is anticipated that payments f $2,500 r mre will be made. (b) Cmplete a separate frm fr each claim. Please cpy and use this frm t reprt any additinal claims. (c) If space is insufficient t answer any questin fully, please attach a separate sheet. (d) LEAVE NO BLANKS. (e) Please neatly print r type all answers. (f) A principal r fficer f the applicant firm must sign this page in additin t the last page f the TIAC Prfessinal Liability (E&O) Applicatin. 1. Name f Applicant: 2. Full name f individual invlved in the claim: 3. Full name f claimant(s): 4. Date f alleged errr. 5. Date f claim: 6. Was there litigatin r arbitratin? YES NO 7. Name f E & O insurer, if any: 8. Present status f claim: CLOSED PENDING IN SUIT IN ARBITRATION 9. If CLOSED: Ttal lss paid: $ Ttal expense paid:$ 10. If PENDING: Amunt asked in suit: $ Claimant s settlement demand:$ Defendant s ffer fr settlement$ Insurer s lss reserve: $ Insurer s expense reserve:$ As f date f applicatin: Ttal lss paid: $ Ttal expense paid:$ 11. Descriptin, including assessment f liability if pending (please prvide enugh infrmatin t allw evaluatin): a. Descriptin f case and events: b. Allegatin(s) upn which claimant bases claim: 12. Explain what actin(s) have been taken t prevent a recurrence r similar claim: The infrmatin submitted herein becmes a part f the Prfessinal Liability (E&O) Insurance Applicatin and is subject t the same representatins and cnditins. Signature f Applicant Date (This frm must be signed by a principal r wner f the Applicant firm) TIAC-2 (09/2010 Ed.) Page 4 f 4

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