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Home > Errors Omissions > Title & Escrow Agent Online Indication Form
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Title & Escrow Agent Online Indication Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Name *
First Name *
Last Name *
Street Address
City, State. ZIP Code
Primary Phone Number *
Fax # *
E-Mail Address *
Year Established
Number of Owners
Number of years experience for each Principal/Partner
Number of Employees
Current Coverage *

Current Insurance Provider
Limits *
Deductible *
Current Premium
Retroactive or Prior Acts Date
Gross Revenue - Last 12 Months
Escrow Services / Closing Services:
Title Agent Commissions:
Abstracting:
Search Fees:
Other (Describe):
Total Gross Revenue:
Provide the % of annual gross revenue by property type:
Residential
Commercial
Construction Loans
Oil & Gas
Mineral Rights
Other (Describe)
Is the Applicant owned by or have any ownership interest in a financial institution, mortgage company, real estate development or investment firm or a title insurance carrier? *

If yes, does the Applicant provide any services to or for these affiliated entities? *


Does the applicant perform 1031 tax deferred exchange services? *

List states where the Applicant performs professional services *
Have any prior E & O insurance policies been cancelled or non-renewed? *

Have you had any E & O Claims in the past FIVE years or do you have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim? *

If Yes to any of the above, provide details including loss runs on a separate sheet of paper.
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Grand Rapids, MI 49546
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