Name *
Address *
City * State * Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip *
Email Address * Daytime Phone # *
Member # / Agency Customer ID (if applicable)
Please note that this is a claims-made policy
Amount of Coverage * $75,000 Per Claim/$150,000 Aggregate $125,000 Per Claim/$250,000 Aggregate
Deductible * $500 $1,000
Effective Date (mm/dd/yyyy) *
State(s) and Expiration Date(s) of Current Notary Commission(s) *
Number of Years Experience as a Signing Agent *
Number of Signings Completed *
Have you taken training and/or been certified to handle signing documents for mortgage lenders, title or escrow companies? * Yes No
Date Training Completed (mm/dd/yyyy) Course Name
Certification Date (mm/dd/yyyy) By Whom
If you carry Notary Errors and Omissions Insurance, what is the limit? $
Any claims filed against any Notary or Signing Agents Errors and Omissions Insurance or have you been sued for activity in regards to a loan signing? *
Yes No If yes, please explain.
Criminal background check done? * Yes No If yes, when?
Notary or Signing Agents organization memberships or affiliations:
Do you keep a journal of Notarial acts? * Yes No
Do you handle closing funds at signings? * Yes No
Notice to Applicant – Please read carefully
Warranty: The applicant warrants that the information contained herein is true as the date this application is executed and understands that it shall be the basis of the policy of insurance and deemed incorporated herein if the Insurer accepts this application by issuance of a policy. Yes, applicant so warrants. No, provide complete details to Company.
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Before submitting your request, be sure to check our list of Frequently Asked Questions. You can also contact us by calling 1-800-331-6053 or faxing us at 1-605-335-0357.
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