E&O Application

General Information

Applicant Name *

Has the name or structure of the Applicant ever changed, or has there been an acquisition, consolidation, merger, dissolution, reconstitution, or any other change?*

Yes No

If you have retro coverage, any past name, DBA, or entity must be named on the policy for coverage.

Provide Details*

Applicant Contact Name and Title*

Physical Address

Address 1*

Address 2

City*

State*

Zip*

Is Mailing address same as Physical address?*

Yes No

Mailing Address

Address 1*

Address 2

City*

State*

Zip*

County

Website

Phone*

Fax

Email Address*

Year Business Established *

Number of Locations*

Officers & Owners

List officers/owners and complete information below.

×

Name*

Birth Year

Title

Ownership %*

%

Active in Daily Business?*

Yes No

Ownership 0% + Add Another Officer/Owner

Total Number of Employees*

Do all active Owners, Officers, or Key Employees performing Professional Services have more than 3 year's experience?*

Yes No

Current / Prior Insurance

Revenue & Operations

12-month Revenue *

$

Your retained commission after premium is paid to underwriters plus revenue from closing, escrow or title searches.

What % of Revenue is

Include any farm and vacant lots in your residential percentage.

Residential %*

%

Commercial % *

%

Oil & Gas %*

%

Total 0%

Is 20% or more of Applicant's work directly from builders during construction or development of property?*

Yes No

If any services are performed by an outside party, are they required to carry their own E&O liability insurance?*

Yes No N/A

The Applicant warrants and/or certifies that it will continue to require subcontractors to obtain and maintain E&O insurance during the life of this policy.

Attach a current Declarations Page or Certificate of Insurance for each subcontractor.

What percent of your independent contractors carry E&O liability insurance?

%

Services

Claims History

Verification

I understand that insurance coverage and/or claims cannot be submitted, bound, amended, cancelled, changed or managed through this form.

I verify I have reviewed and accepted our Notices. I also acknowledge that I can opt out of future email correspondence, delivery of future quote or policy documentation or other digital correspondence by emailing [email protected] .

By typing my name to digitally sign this application in the box below, I agree that after inquiry of all applicants and prospective insureds, no person proposed for coverage is aware of any fact or circumstance which reasonably might give rise to a future claim that would fall within the scope of the proposed coverage.

Authorized Signature

Date

General Information

Officers & Owners

List officers/owners and complete information below.

Current / Prior Insurance

Deductible & Requested Limits

Revenue & Operations

What % of Revenue is

Services

Title Agent

Abstractor / Searcher

Escrow Agent / Closer

Claims History

Verification