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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
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
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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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