This completed document should be submitted to:
Old Republic Professional Liability, Inc.
191 North Wacker Drive, Suite 1000
Chicago, IL 60606-1905
T: 312.750.8800	www.oldrepublicpro.com

TITLE INSURANCE AGENTS APPLICATION ADDENDUM

1.	Name of Applicant:  	      
					(Name of law firm)

2.	List all partners, officers, shareholders or employees of the applicant who act as title insurance agents:
	Name	Position/Title	Name	Position/Title
	     	     	     	     
	     	     	     	     
Continue on a separate addendum, if necessary.

3.	List the title insurance companies represented and when representation began:
     	Name of Company	Month/Year	
	     	     	
	     	     	
	     	     	
	Continue on a separate addendum, if necessary.
	
4.	(a)	State the total number of policies issued during the past twelve (12) months:
		Type of Property	   	Number of Polices
		Residential:		     
		Commercial/Industrial:	     
		Farm/Ranch:		     
		Other -      			     
	              Total:		0

(b)	How many of the policies shown in (a) above involve properties where the title search was performed by a lawyer of the applicant?      

5.	State the total commission income derived from title insurance agent activities:

      	(a)  	Second previous fiscal year:  	$     
(b)  	Immediate past fiscal year:	$     
(c)  	Current fiscal year (estimate):	$     
	
6.	Are title insurance policies processed and issued through a separate business entity owned by the applicant or any of the applicant’s lawyers or other employees?     Yes    No. If yes, please explain in detail:
	
	     
     

7.	Do the applicant or any of the applicant’s lawyers or other employees own a financial interest in any of the title insurance companies shown in question 3?   Yes    No. If yes, please explain in detail:
	
     
     	
8.	Has any title insurance company canceled or terminated its agency contract with the applicant or any predecessor firm during the 	past five (5) years?     Yes    No. If yes, please explain in detail:  NOT APPLICABLE IN MISSOURI
	
     
     	
9.	Are closing protection letters obtained from the title company prior to closing on a property sale? 	 Yes    No  

10.	During the past five (5) years has any claim been made against the applicant or any predecessor firm or any of the applicant’s present lawyers or employees or any of the applicant’s (or predecessor firm’s) former lawyers or employees with respect to their activities as title insurance agents?     Yes    No. If yes, please explain in detail:
	
     
     
     	
11.	After inquiry of all present lawyers and other employees, does the applicant know of any facts or circumstances with respect to their activities as title insurance agents that could reasonably give rise to a claim against the applicant or any predecessor firm or any of the applicant’s present lawyers or employees or any of the applicant’s (or predecessor firm’s) former lawyers or employees?               Yes    No. If yes, please explain in detail:
	
     
     
     	
No coverage will be afforded under the proposed Lawyers Professional Liability policy for any claim arising out of any matters disclosed or required to be disclosed in response to question 11.  To avoid loss of coverage, all known facts or circumstances that may reasonably give rise to a claim should be reported to your present insurer within the time period specified in your present policy.	

NOTICE

I understand that the information submitted herein becomes a part of my professional liability application and is subject to the same warranty and conditions.

Must be signed and dated by an Owner, Partner or Principal as duly authorized on behalf of the Applicant.

							                       		     	                                                                                           
  Signature of Owner, Partner or Principal				                Date

Fraud Warning

(All States except: AL; AR; CO; DC; FL; HI; KS; KY; LA; ME; MD; NJ; OH; OK; OR; PA; TN; WA)

Any person who knowingly presents a false or fraudulent claim for payment 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 civil fines and criminal penalties.

Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Arkansas – Any person who knowingly presents a false or fraudulent claim for payment 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.

Colorado – 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.

District of Columbia – WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.  In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida - Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. 

Hawaii – For your protection, Hawaii Law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Kansas – Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

Kentucky – Any person who knowingly and with intent to defraud any insurance company or other 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.

Louisiana – Any person who knowingly presents a false or fraudulent claim for payment 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.

Maryland – Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Ohio – Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime.

Oklahoma – 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.

Oregon – Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application containing a false statement as to any material fact, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

Pennsylvania – 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 subjects such person to criminal and civil penalties.

Maine; Tennessee; Washington – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines, and denial of insurance benefits.

IOWA Applicants Only

The insurance for which this is an application 
was solicited by:

Print name: 	

Iowa license number: 	

Agency: 	

NEW HAMPSHIRE ONLY; FOR PRODUCER USE ONLY

Agency Name and Address:		

		
Agent’s New Hampshire
License I.D.#:		

Agent’s Signature:		
(stamped signature is not acceptable)

FLORIDA ONLY
FOR PRODUCER USE ONLY

Agency Name and Address:  		

		

Agent’s Florida License I.D.#:  		

Name of Agent:   		

Agent’s Signature:  		

Agent’s Name (printed):