AGENCY PROTECTION PLUS Application Contact Information Applicant Name DBA Contact Title Phone Fax Email Street Address 1 Street Address 2 City State Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missourri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming ZIP Website Year Established Number of Locations Number of Entities/DBAs Staff Size (Include any owners who are active in the business) Years representing Stewart Title (Years that you have represented Stewart Title an an independent agent) Stewart Agency Code Stewart Rep Is the Applicant controlled, owned, affiliated or associated with any other organization? Yes No Does any Person/Entity with ownership interest in the Applicant also own, control or manage another entity? Yes No If so Name of Organization Type of Organization Relationship Are services provided to the Organization? Yes No % of applicants business Has the name or ownership of the Applicant ever changed or has any other entity been acquired, merged or consolidated with the applicant? Yes No Are owners active in daily operations of the business? Yes No Are background checks performed on new hires? Yes No Title Underwriters Represented List top three title insurers with whom business is or has been placed in the last three years. All information must be complete. Include any bar-related title insurer or fund. Title Underwriter 1 Name of Company Date First Represented Premium Remittance (Current Annual Premium Remittance) Title Underwriter 2 Name of Company Date First Represented Premium Remittance (Current Annual Premium Remittance) Title Underwriter 3 Name of Company Date First Represented Premium Remittance (Current Annual Premium Remittance) Revenues Total gross revenue from all services (Annualized) Prior fiscal year Estimate of coming year Check applicable revenue source(s) and indicate the revenue breakdown from each service. Commissions (Title Insurance Commissions) Abstract/Search Fees Escrow/Closing Fees Other Total Provide percentage of annual gross revenue by category. Residential Commercial/Industrial Agricultural Oil/Gas Other Total Title Transaction Information What percentage of applicant’s title searches are performed by a title insurer? Are applicant’s title searches, closings or other services performed by independent contractors? Yes No % of applicants business Are 1031 tax-deferred exchange services provided? Yes No Does applicant have an Escrow Security Bond™ in force? Yes No Currently using AgencySecure® or Stewart Financial Services? Yes No Minimum of one week vacation required for staff? Yes No Is there segregation of duties so that no single transaction can be fully controlled from initiation to recording by one person? Yes No Are voice or facsimile-initiated wire transfers performed? Yes No If yes, are independent-call-back procedures in place? Yes No Are dual signatures required for checks written from the operating account or is an owner/manager required to sign checks? Yes No Are bank accounts, including escrow and trust accounts, reconciled by someone not authorized to deposit or withdrawal? Yes No Is a three-way reconciliation of bank account to the control account and to the trial balance prepared monthly and any unusual reconciliation issue investigated properly? Yes No Have there been any employee dishonesty losses in the past five years, or are you aware of any situations that may result in a loss due to employee dishonesty? Yes No Have any claims/suits been made in the past five years against the applicant, any officers or employees, or its predecessor firm? Yes No Is the applicant, its predecessor firm or any of the officers or employees of the firm aware of any circumstance, act, error or omission which may result in a claim against them? Yes No Current E&O Coverage Expiration Date Deductible Carrier Premium Limits Retroactive or Prior Acts Date Personal Information Name Title The undersigned represents and warrants on behalf of the Named Insured and all persons/entities for whom this insurance is being purchased, that to the best of your knowledge and belief, the statements set forth herein and attached hereto are true and accurate and that there has been no attempt at suppression or misstatement of any material facts known or that should be known. We will rely upon this application and all such attachments in issuing the policy. Submit
