Renewal Application - Miscellaneous Professional Liability by XtiUx0

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									                    ACE American Insurance Company
                    Illinois Union Insurance Company                                    ACE Advantage®
                    Westchester Fire Insurance Company
                    Westchester Surplus Lines Insurance Company

                             TITLE AGENTS / ABSTRACTORS / ESCROW AGENTS
                                  PROFESSIONAL LIABILITY RENEWAL APPLICATION
   1. Company Name (Applicant):
      Full Mailing Address
      Phone #:                _           Fax#:                    __       E-mail:
      Contact person:

   2. Total gross revenues of Applicant and all insured subsidiaries for the last 12 months: $
        Abstracting /Searches/Title Insurance        % Escrow/Closing Fees _             %
        1031 exchanges*                              % Other (explain)             _____ %
        * If there is any work concerning 1031 exchanges, provide full details on a separate sheet.
   3. Does Applicant or any insured subsidiary become involved in any work concerning oil, gas or precious
      metals/minerals? Yes ____ No      _ If Yes, provide full details on a separate sheet.
   4. During the last 12 months have there been any changes to the ownership structure of Applicant or did Applicant
      acquire, consolidate with, merge with or dissolve any entity? Yes            No         _
      If Yes, provide full details on a separate sheet.

   5. During the last 12 months has the Applicant changed the scope of their professional services?
      Yes ______ No ______         If Yes, provide full details on a separate sheet.
   6a. Have any claims or suits been made during the past 12 months against the Applicant, any insured subsidiary,
       their predecessor firms or any of the partners, principals, directors, officers, employees or independent
       contractors of the Applicant or any insured subsidiary? Yes           _ No _______

   6b. Is the Applicant, any insured subsidiary, their predecessor firms or any partner, principal, director, officer,
       employee or independent contractor of the Applicant or any insured subsidiary aware of any circumstance,
       act, error or omission which may result in a claim against any of them? Yes ______ No ______

       If Yes, to either 6a &/or 6b, complete the claims supplement for each claim or circumstance. Please note that this
       does not constitute the reporting of any claim or incident to the insurer, and any claims or incidents must be
       reported in accordance with the terms and conditions of the expiring policy.

   7. Does the applicant use independent contractors? Yes ______ No ______
      a. Does the applicant require the independent contractors to carry E&O liability insurance? Yes ____ No            _
         If yes, please provide proof of coverage.

The undersigned represents that the statements set forth herein and in the attachments hereto are true and accurate and
that no material facts have been misstated, misrepresented, suppressed or concealed, and agrees that this application
shall become the basis of any coverage and part of any policy that may be issued by the insurer as if physically attached
thereto. If after the date of this application and prior to the effective date of any policy based on this application, any
occurrence, event or circumstance should render any of the information contained in this application or attachments
hereto inaccurate or incomplete, then the undersigned shall notify the insurer of such occurrence, event or circumstance
and shall provide the insurer with information that would complete, update or correct such information. Any outstanding
quotations may be modified or withdrawn at the sole discretion of the insurer. The execution of this application does not
bind the undersigned to purchase any coverage offered, nor does the review and/or receipt of this application bind the
insurer to issue a policy or offer coverage.
Applicant Signature: No            ___________________                                                            _
                                                                                    Date
Name and Title (Please Print):___________________________________________________________
The application must be signed and dated by an owner, partner or officer of the applicant Company within ninety (90)
days prior to the policy inception date.

PF-28291 (08/11)                                                                                                  Page 1 of 2
FRAUD WARNING STATEMENTS

NOTICE TO ARKANSAS, ARIZONA, DISTRICT OF COLUMBIA, FLORIDA, KENTUCKY, LOUISIANA, NEW MEXICO,
PENNSYLVANIA, TENNESSEE, VIRGINIA, AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH
INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE
CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND
SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO
DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL
DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE,
INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF
DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR
AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE
WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.

NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY
INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.

NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.

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 OR STATEMENT OF CLAIM CONTAINING ANY
MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, COMMITS A       FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR
EACH SUCH VIOLATION.

NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A
FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE
STATEMENT IS GUILTY OF INSURANCE FRAUD.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE,
DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING
ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.

NOTICE TO OREGON APPLICANTS: ANY PERSON WHO, WITH INTENT TO KNOWINGLY DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY
MATERIALLY FALSE OR DECEPTIVE INFORMATION THAT IS MATERIAL TO THE ACCEPTANCE OF THE RISK OR TO THE
CLAIM COMMITS A FRAUDULENT INSURANCE ACT AND MAY BE COMMITTING A CRIME.

NOTICE TO RHODE ISLAND APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENTS OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.

NOTICE TO ALL APPLICANTS:

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON,
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS INFORMATION FOR THE PURPOSE OF MISLEADING, COMMITS A FRAUDULENT INSURANCE
ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.


PF-28291 (08/11)                                                                           Page 2 of 2

								
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