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?*