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
Required
|
|
| First Name
Required
|
|
| Last Name
Required
|
|
| Street Address
Optional
|
|
| City, State. ZIP Code
Optional
|
|
| Primary Phone Number
Required
|
|
| Fax #
Required
|
|
| E-Mail Address
Required
|
|
| Year Established
Optional
|
|
| Number of Owners
Optional
|
|
| Number of years experience for each Principal/Partner
Optional
|
|
| Number of Employees
Optional
|
|
| Current Coverage
Required
|
|
| Current Insurance Provider
Optional
|
|
| Limits
Required
|
|
| Deductible
Required
|
|
| Current Premium
Optional
|
|
| Retroactive or Prior Acts Date
Optional
|
|
|
|
Gross Revenue - Last 12 Months |
| Escrow Services / Closing Services:
Optional
|
|
| Title Agent Commissions:
Optional
|
|
| Abstracting:
Optional
|
|
| Search Fees:
Optional
|
|
| Other (Describe):
Optional
|
|
| Total Gross Revenue:
Optional
|
|
|
|
Provide the % of annual gross revenue by property type: |
| Residential
Optional
|
|
| Commercial
Optional
|
|
| Construction Loans
Optional
|
|
| Oil & Gas
Optional
|
|
| Mineral Rights
Optional
|
|
| Other (Describe)
Optional
|
|
| 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?
Required
|
|
| If yes, does the Applicant provide any services to or for these affiliated entities?
Required
|
|
| Does the applicant perform 1031 tax deferred exchange services?
Required
|
|
| List states where the Applicant performs professional services
Required
|
|
| Have any prior E & O insurance policies been cancelled or non-renewed?
Required
|
|
| 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?
Required
|
|
| If Yes to any of the above, provide details including loss runs on a separate sheet of paper.
Optional
|
|
Submission Validation Required |
Enter the Validation Code from above.
|
Important NoticeAny
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.
|