APPLICATION FOR TITLE AGENT PROFESSIONAL LIABILITY COVERAGE

---

NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY. COVERAGE IS WRITTEN ON A SURPLUS LINES BASIS. RATES BELOW ARE FOR APPLICANTS POSSESSING THE FOLLOWING RISK CHARACTERISTICS: • Generates less than $200,000 in revenues annually  • No E&O claims over past 3 years  • Not Domiciled in CA, KY, NC, WA

STEP 1.  DETERMINE BASE COVERAGE AND LIABILITY LIMITS DESIRED

COVERAGE CHOSEN (SELECT ONE) Limit of Liability Retention Retro-Date Inception OR Prior Acts Cover $ 500,000 / $ 500,000 $ 5,000   $ 1,000   $ 1,200 $1,000,000 / $1,000,000 $ 5,000   $ 1,250   $ 1,500   * PROOF OF PRIOR COVERAGE REQUIRED   Desired Effective Date:      STEP 2.  OPTIONAL ENDORSEMENT     Coverage for Transactions Requiring Maintenance of Escrow Funds   Subject to a sub-limit of $100,000 and a $10,000 retention. Additional Premium: $250.00   Selected Coverage: $0.00   Escrow Coverage Option: $0.00   Taxes and Fees (Required): $200.00   TOTAL AMOUNT DUE: $0.00

A.
	Applicant Name:
	Business Address:
	City:		State:	--Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip:
	Phone:	() -	Fax:	() -
	Email:			Years in Business:
	Title Companies Represented:
	Indicate, by percent, what sources are used to compile title data (Must equal 100%):

	In-House Index	%	Courthouse Records	%	Title Insurance Company Resources	%
	Outside Abstractor/ Searcher	%	Other (describe)			%
	Does the firm use outside sources to perform title searches?				Yes No

	B.  List the outside title search firms used.  Attach additional sheets if necessary:
	FIRM No. 1
	Outside Source Name:
	Business Address:
	City:		State:	--Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip:
	Years Experience in Abstracting/Searching Files:
	FIRM No. 2
	Outside Source Name:
	Business Address:
	City:		State:	--Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip:
	Years Experience in Abstracting/Searching Files:
	C.  Do any of the contractors listed in "B" above maintain their own Errors & Omissions insurance?					Yes No

D.	FINANCIAL AND BUSINESS INFORMATION
	1. Total commission income, last 12 months:		$
	2. Total commission income, next 12 months (estimated):		$
	Show revenue breakdown by the following categories:
	Title/Policy Commissions:	$	Escrow/Closing Fees:	$
	Abstracting/Searching Fees:	$	Other (describe):	$
	3. What is the approximate percentage breakdown of total income for the following categories (Must equal 100%):
	Residential:	%	Commercial/Industrial:	%
	Oil/Gas:	%	Agricultural:	%
	Precious Metals/Minerals (i.e., coal, gravel, etc.):	%	Other (describe):	%

E.	PRIOR INSURANCE
	1.	Do you currently have an Errors & Omissions Insurance policy?		Yes No
		If "Yes", specify carrier:		Retroactive Date:
	2.	Has any proposed Insured ever been the subject of disciplinary action by authorities as a result of their professional activities?			Yes No
		If "Yes", please explain
	3.	Does the person to be insured have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim against him/her?			Yes No
		If "Yes", please explain
	4.	After inquiry have any claims been made against any proposed Insured(s) during the past five (5) years?			Yes No
		If "Yes", please explain

PAYMENT OPTIONS
	A.	Check For Full Amount Due, Payable to Fox Point Programs, Inc.
	B.	Credit Card:	VISA  Mastercard  AMEX	Card Number:
				Expiration Date:	01 02 03 04 05 06 07 08 09 10 11 12 / 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
	Applicant Statement & Agreement
			BY CHECKING THIS BOX, 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 MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.
			Notice to New York applicants: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.     The Applicant hereby acknowledges that he/she/it is aware that the limit of liability shall be reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the Insurer shall not be liable for the costs of legal defense or for the amount of any judgement or settlement to the extent that such exceeds the limit of liability.     The Applicant hereby further acknowledges that he/she/it is aware that legal defense costs that are incurred shall be applied against the deductible amount.