$100,000 Errors and Omissions Insurance Application

A simple application is required to obtain the $100,000 Errors and Omissions Insurance.
After completing the form, you will have a chance to review it before sending the results to NotaryX.com.
Once it is received, we will review the form. Incomplete forms may delay issuing of the E&O policy.

Throughout the application the terms "you" and "your" mean the licensed Notary Public who is applying for this insurance.

Name - type your full name (or your name as it will appear on your notary seal)
Address - enter your street or postal box address
City - the name of your city
State - two letter state abbreviation (CA for California)
Zip Code - Zip code or extended zip code

INSTRUCTIONS: All questions must be answered accurately and completely. If additional space is needed, submit a separate page and refer to the question number.
Check the box indicating that you understand the instructions. I will answer accurately and completely.
I will not answer accurately and completely.
GENERAL INFORMATION

1. Check the box which provides the best description of the documents that you notarize or plan to notarize: Loan Signing Documents
Immigration Documents
A variety of documents including loan signing, immigration, vehicle, personal statements and all other legal documents.

2. Has a claim ever been filed against your Notary Bond or Notary E&O Policy? Yes
No
If Yes, please explain:

3. Are you currently in violation of any rules/regulations of the Notary Board in your state? Yes
No
If Yes, please explain:

4. Have you completed the necessary requirements (courses) to obtain your Notary license? Yes
No
If No, please explain:

5. Are you currently in compliance with ALL your state's Notary license requirements? Yes
No
If No, please explain:

6. Do you use a notary journal for all transactions, and is it stored in a secured drawer or box? Yes
No
If No, please explain:

7. Do you only witness signatures of individuals who appear before you personally? Yes
No
If No, please explain:

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 and fact material thereto, commits a
fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
Check the box indicating that you understand the instructions. I understand that a fraudulent insurance act is a crime.
I do not understand this instruction.
YOUR SIGNATURE AND AUTHORIZATION

The undersigned declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements set forth in the
attached application for insurance are true and complete and may be relied upon by the company. If the information in any
application changes prior to the inception date of the policy, the applicant will notify the company of such changes, and the company
may modify or withdraw any outstanding quotation. The company is authorized to make inquiry in connection with this application.

The signing of this application does not bind the company to offer, nor the applicant to purchase, the insurance. It is agreed that this
application, including any material submitted therewith, shall be the basis of the insurance and shall be considered physically attached
to and part of the policy, if issued. The company will have relied upon this application, including any material submitted therewith, in
issuing the policy.

Electronically reproduced signatures will be treated as original.

Check the box indicating that you understand the instructions. I understand these instructions and agree to sign electronically.
I do not understand these instructions.
Type your name as it will appear on your notary stamp
Date of signing
City where completing this form
State where completing this form
Your commission number

After clicking the submit button, you will have a chance to check the information for accuracy. Be sure that it is entered accurately.

Once you have completed this step, you will be returned to the store.

Return to the Notary Store