Expedited Premium Estimate Form

Items marked with * are required.

1. Contact Information

Please enter your contact information below.

Contact Name*

Firm Name

Address*

City*

State*

ZIP Code*

Phone*

Fax

Email*

2. Staff Size

Please enter the total size of your staff below. Include all owners, officers and employees engaged in abstracting, searching, title underwriting, title opinions, escrow/closing, recording, commitment and policy preparation.

Staff Size

3. Estimated Annual Gross Income For Past 12 Months

Please enter your Estimated Annual Gross Income below. If a new entity, use next 12 months estimate.

a. Title Agency Commisions
Excluding payments to underwriters.

b. Abstracting/Searching Fees

c. Escrow/Closing Fees

d. Other (describe)

TOTAL

4. Current E&O Insurance

Name of Insurer

Retroactive Date

Current Limit of Liability

Deductible

Annual Premium

Expiration Date

5. E&O Claims

Have you had any E&O claims in the past 5 years?
YesNo

6. How Did You Hear About TIAC?*