Affinity Insurance Agency, Inc.
Title Agents & Abstracters Professional Liability
TO: Affinity Insurance Agency
3950 Cobb Parkway, Suite 707
Acworth, GA 30101
Tel. 770-974-5502
Fax 770-974-5359
Just give us a few facts about your firm and we can provide you with a premium estimate. We will need to see a fully completed application before we can send you a firm quote, but this should be enough information for a reasonably good estimate.
1. Full legal name of firm:
Address:
Contact Person:
City:
State:   Zip:
Phone:
Fax:
Email:
# of  locations:
Website:
   

Web Consent Form:   By entering my firm name, fax number (s), and my name above, I am authorized to and consent to the firm receiving faxes sent by or on behalf of Affinity Insurance Agency, Inc.
1.   Is applicant controlled by, owned by, or commonly owned, affiliated with any other organization?
YES NO (*If “yes” please attach explanation at the bottom of the page.)
In the past five years has the name of the firm changed or has any other business been purchased, merged or consolidated?
YES NO (*If “yes” please attach explanation.)
 

2.   Provide the number of: Employees:  Owners active in the business: Total staff, employees and active owners   Years of experience for each principal:
 
3.   Date firm founded:
 
4.   What is your gross revenue split in DOLLAR AMOUNTS (for the most recent 12 months)?
Title Agent:
$  
Abstracting/Title Search:
$  
Settlements/Escrow
$  
Other (please describe)
$ 
5. Provide the percentage of gross income/revenue by type:
 Residential %    Commercial    %     Agricultural %   Construction Loans %
 UCC Reports %   1031 Exchanges* %
*For 1031 exchanges, are you performing closings only and not as a Qualified Intermediary?
YES NO

6. Have you had or reported any professional liability claims within the last five (5) years?
YES NO

7. Do you have knowledge or information of any incident, act, error, or omission that could reasonably result in a claim?
YES NO
Have you or anyone applying for coverage ever been the subject of a disciplinary action or investigation or complaint as a result of any professional activities?
YES NO

If “yes” to any of the above, please attach an explanation at the bottom of the page including dates, amount paid, reserved, and what you did to avoid similar problems.


8. Has any prior E & O insurance policies been cancelled or non-renewed?
YES NO (If “yes” please attach explanation at the bottom of the page.)

9. Firm’s Professional Liability coverage:
Current professional liability Insurer:
Expiration Date of Policy:
Retroactive Date of Policy:
Current Limits of Liability:
Deductible:
Current Premium: 
Limits of Liability Desired: 
Deductible Desired:

Please provide an explanation if required:


 

3950 Cobb Parkway, Suite 707 Acworth, GA 30101
Tele. (770) 974-5502 * Fax (770) 974-5359
June 2008