GENERAL INFORMATION

Full Name
Firm Name
Business Address
Home Address
Business Phone	Fax:

EXPERIENCE
Years of Title Experience
Number of Titles Examined
Number of Settlements Held
Year Admitted to the Bar
State of Primary Practice
Additional States Admitted

CLIENTELE:  
Which Lenders are responsible for the largest portion of your title business?

Institution Name:	Location:

EDUCATION: 
Please list names and locations for each institution attended, time spent at each, and degree received (if applicable).

Institution Name	Location	Dates Attended	Degree Received

BANK REFERENCES: 
Please provide the name, address, and account representative for each financial institution with which you maintain accounts.  For each account, include the account number, type of account, and purpose for that account.
1.
2.

TRADE REFERENCES: 
Please provide names, addresses, and account representatives for at least two businesses with whom accounts are maintained.
1.
2.

PROFESSIONAL REFERENCES: 
Please provide names and addresses of five people who have personal knowledge of your title experience and/or personal integrity.  At least three of those named must be practicing attorneys.
1.
2.
3.
4.
5.

OTHER INFORMATION:
Please List any states and counties in which you have practiced law or done title work:

Approximate number of closing held and remittances to underwriters for each of the last 12 months:

Number	Remittance	Number	Remittance	Number	Remittance
Jan:		May:		Sep:
Feb:		Jun:		Oct:
Mar:		Jul:		Nov:
Apr:		Aug:		Dec:

Anticipated Number of Closings over the next 12 months:
Choose 1-20 21-40 41-60 61-100 101-150 151-200 201-250 251-300 > 300

In what percentage of your real estate closings is a title insurance policy issued?
Choose < 50% 51%-75% 76%-100%

The average amount of a transaction in your real estate practice is:
Choose < $50,000 $50,001-$100,000 $100,001-$150,000 $150,001-$200,000 $200,001-$250,000 > $250,000

Do you have at least one paralegal/clerk/secretary dedicated to the real estate practice?
Choose Yes No

Have you ever been or are you currently an Examining Counsel or Approved Attorney for another title insurance company?
Choose Yes No

Have you or any of your staff (partners, shareholders, etc.) ever been the subject of an investigation related to the quality of your work or the handling of funds?
Choose Yes No     If YES, please explain:

Have you ever had any claims filed against you?
Choose Yes No     If YES, please explain:

Has your Agency contract ever been terminated for any reason?
Choose Yes No     If YES, please explain:

Are you a member of the Real Estate and Probate Section of your state's Bar Association?
Choose Yes No     

Do you have a separate escrow or trust account for real estate settlement funds?
Choose Yes No

PLEASE COMPLETE THE FOLLOWING FOR ALL OWNERS AND ACTIVE OFFICERS OF YOUR AGENCY. 
All listed agree to obtain their credit report.

1.	Name
	Title
		Ownership Percentage
	Home Address
	Other Business Interests
		Social Security Number

2.	Name
	Title
		Ownership Percentage
	Home Address
	Other Business Interests
		Social Security Number

3.	Name
	Title
		Ownership Percentage
	Home Address
	Other Business Interests
		Social Security Number