Name of person completing this application:

1. Name of agency:

2. Address:

3. Telephone: 4. Fax: 5. Email:

6. Year this agency started doing business: 7. State: 8. Tax I.D. #:

9. Agency ownership (indicate percentage of ownership):

10. List company key decision makers, their position, and years of title experience (EACH PERSON LISTED MUST COMPLETE A SUPPLEMENT PERSONAL INFORMATION SHEET):

11. List escrow account authorized signatories, their position, and years of title experience (EACH PERSON LISTED MUST COMPLETE A SUPPLEMENT PERSONAL INFORMATION SHEET):

12. If company performs closings and closing protection letters are required, list any and all additional title personnel handling the intake and disbursement of funds and preparation of closing packages. Include years of experience:

13. List all principals/employees authorized to sign commitments and policies. Include years of title experience:

14. Are any of the owners, partners or key employees of this agency employed by or possess an interest in any of the following (check all that apply):

Real estate sales Mortgage Broker Building/Construction Co

Real estate developer Savings and Loan/Bank/Lender

If YES, list principal, name of company, position held and their percentage of ownership interest :

15. List any customers in which you receive more than 10% of your overall business.

16. Does the agency insure transactions in which the owner, owner’s family or officer(s) have an interest? If YES, provide the name and applicable transaction/project info.

IMPORTANT NOTE: These transactions must be approved by the Company.

17. Anticipated Annual NET remittances to underwriter $

18. Are closings/settlements performed in house? Yes No Average per month?

19. Are Closing Protection Letters required? Yes No

20. Do you maintain a title plant? If Yes, indicate ownership and brief description:

21. Are search and exam functions performed in house? Yes No If NO, please provide your source of title evidence:

22. List all title insurance underwriters you have represented:

UnderwriterName of AgencyStatusYears

NOTE: If you have been involved in litigation with any of your underwriters or have been terminated by any of your underwriters in the past, please attach an explanation for each event.

23. Liability coverage(s) presently maintained (a copy of the policy must be provided):

Yes No Errors & Omissions Insurance

Yes No Fidelity Bond

Yes No Surety Bond

Are all premiums paid? Yes No Are premiums financed? Yes No

NOTICE: This application and information contained herein shall survive the execution of valid Agency Agreement and shall become part of said Agreement. If any statement contained in this application shall be false, such be grounds for termination of the Agency Agreement.

All principals and/or officers of the above Agency as set forth herein are over the age of eighteen (18) years and are bona fide residents of this state unless otherwise set forth above. The agency is qualified to do business in said state; maintains an office therein accessible to the general public at the address set forth above; all persons examining titles, issuing policies or commitments of title insurance and handling closings have the training and experience necessary to properly perform such functions.

Pursuant to the Fair Credit Reporting Act (Public Law 91-508), we are required to inform you that as part of our normal procedure for processing your application for approval as an agent, a routine inquiry may be made concerning information on your character, general reputation and financial status. Further information on the nature and scope of such inquiry, if one is made, is available to you upon written request.

I hereby certify and affirm that all information in this application is true and correct to the best of my knowledge and belief and I agree that the Company shall have the right to decline the approval of this application.

Signature: ______Date: ______

Title/Position held: ______

NOTE: Please attach copies of current financial statements or proformas in case of a new entity.