Notary Public Professional Liability Insurance Application Form

Applicant Information

Full Name Business/Organization Name Mailing Address City State ZIP Code Phone Number Email Address

Notary Information

Notary License Number License Issuance Date License Expiration Date Years as a Notary Public

Coverage Details

Requested Coverage Limit $25,000 $50,000 $100,000 $250,000 $500,000 Requested Deductible

Claims & Disciplinary Actions

Have you ever had any claims filed against you as a notary? No Yes If yes, provide details Have you ever been subject to disciplinary action? No Yes If yes, provide details

Additional Information

Comments or Additional Information