Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405
Email: Ben@allprocoverage.com





Name

Company Name

Street Address

City

County

State

Zip Code

Phone Number

Fax Number

Email Address

If you have multiple office locations, please list each location here.

Which association(s) do you belong to?

Please list all States in which you perform title services.

Policy Effective Date

What type of business formation?

How many years experience do you have in this field of business?

What year was this company established?

Does your company have any ownership interest in a financial institution, mortgage company, real estate development firm, investment firm or title insurance carrier?

If yes, does your company provide any services to or for these affiliated entities?

Does your company perform 1031 tax deferred exchange services?

What were your prior year total gross revenues?

What is your projected annual gross revenue from title services?

What is your projected annual gross revenue from residential work only?

What percentage of your work includes the subcontracting of work to others?

Do you require your subcontractors to carry E&O insurance?

If you DO NOT require subcontractors to carry E&O, please advise why.

What percentage of your services is provided under written agreement?

Do you have a process to handle and resolve all client complaints?

Do you require continuing education for all professional employees?

Do you hold funds in escrow?

If “yes”, what is the average monthly balance in your escrow account?

Do you have a Fidelity Bond (Not Surety or Title Agent Bond) in place?

If “yes”, what is the face amount of the bond?

Do you maintain a Crime/Employee Dishonesty Bond?

If “yes”, what is the policy limit of the Crime Bond?

Please check the services that are provided (check all that apply):
 Title Agent Closing, Escrow/Settlement Agent Abstractor, Searcher or Title Examiner Witness Closing or Signing Agent Other Services (doc prep, courtesy filing, etc.

Revenue Breakdown by service provided as title agent, closing/escrow/settlement agent, abstractor, searcher, title examiner, witness closing/signing agent, etc. (Please list out, must add up to 100%):

What level of coverage are you interested in?

What are your current E&O Limits?

What is your current E&O deductible?

Who is your current E&O carrier? If none, state NONE.

What is the retroactive date on your current E&O policy?

Current annual premium

p>If you do not currently carry E&O Insurance, please advise why (to explain to the underwriters).

In the past 5 years, has any professional liability claim or suit been made against your or any of the predecessor firms?

If yes, please provide # of claims, year most recent claim was reported and total amount paid for each claim

Do you pay your insurance in installments throughout the year?

How did you hear about us?

Additional Comments:

Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

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Zolofra Insurance Agency
P.O. Box 8787
Red Bank, NJ 07701
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
Email: Ben@allprocoverage.com
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