CHICAGO TITLE AND TRUST FAMILY OF UNDERWRITERS
APPOINTMENT APPLICATION FOR ISSUING AGENT To be completed by applicant Name of Person completing this application: ________________________________________________________________ 1) This agency is a *Attorney/Law Firm *LLC *Association *Partnership *Corporate/Partnership *Sole Proprietorship
Name of Agency _______________________________________________________________________________ D/B/A (if any) _______________________________________________________________________________
Current Business Address ________________________________________________________________________ City________________________________________ State _____________________________ Zip ____________ Phone #_______________________________ Fax #________________________ E-Mail ____________________ Years in Business ___________________ State _____________________________ 2) Tax ID #_______________
Owner’s of Agency. (Indicate percentage of Ownership Interest) ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________ ________
3)
List Company/Firm decision-makers and their position: (NOTE EACH PERSON LISTED MUST COMPLETE AND ATTACH A “PERSONAL INFORMATION SHEET”) ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
4)
If agency performs closings and insured closing letters are required list the following information regarding those employees who prepare loan closing documents, review closing instructions and handle disbursement of loan proceeds. NAME TITLE YRS EXPERIENCE __________________________________________ ___________________________________________________ __________________________________________ ___________________________________________________ __________________________________________ ___________________________________________________ Account Signatories: (NOTE: EACH PERSON LISTED MUST COMPLETE AND ATTACH A “PERSONAL INFORMATION SHEET”) _______________________________________________________________________________________________ _______________________________________________________________________________________________
Active Officers countersigning commitments and policies. NAME TITLE YRS EXPERIENCE __________________________________________ ___________________________________________________ __________________________________________ ___________________________________________________ __________________________________________ ___________________________________________________ 5) List branch offices of agency, name of managers and number of employees at each location. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 6) If agency is a partnership with group of attorneys, list all attorneys who will be involved in an ownership capacity and generate real estate business, or search, examine and close title transaction ATTORNEY FUNCTION ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 7) Anticipate Annual Net to underwriter $________________ Total Residential Orders ______________per month? Total Commercial Orders _______________ per month? Are Insured Closing Letters required? ______________ What percentage of total to underwriter? ___________ 8) Corporate Agents. EXISTING-Attach current operating & financial statements. NEW -Attach pro forma operating statement for one year. Do you maintain a title plant? INDICATE OWNERSHIP AND BRIEF DESCRIPTION.________________________ _______________________________________________________________________________________________ Do you perform examinations from the courthouse? ____________________________________________________ What is the source of independent title evidence?_______________________________________________________ _______________________________________________________________________________________________ 10) 11) Do you close real estate transactions? ________________________ Average per month? _______________________ Liability coverage presently maintained in the applicant’s name: (ATTACH COMPLETE COPY WITH ALL ENDORSEMENTS AND RIDERS. THIS APPLICATION CANNOT BE PROCESSED WITHOUT ALL POLICY INFORMATION.) _________ YES _________ YES _________ YES _________ YES _________ YES _________NO _________NO _________NO _________NO _________NO Do you carry E&O Insurance? Do you carry Fidelity Bond? Do you carry Professional Liability (Atty/Law firm only)? Are all premiums fully paid? If not, explain. OR Are premiums financed? _________YES _________NO Monthly?
9)
12)
List title insurance underwriters you have represented and the status (active, canceled or terminated) and your length of experience. (ATTACH KEY CLAIMS HISTORY FOR ALL UNDERWRITERS) UNDERWRITER STATUS YEAR ______________________________________________________ ______________________ ______________ ______________________________________________________ ______________________________________________________ If terminated, attach letter from underwriter stating reason. A. Total estimated net annual title premium paid to underwriters for last 3 years: $_______________________ $_______________________ $_______________________ Have you or your Company/Firm ever been involved in litigation with your underwriters? __________________ (IF YES, PLEASE EXPLAIN) _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ ______________________ ______________ ______________________ ______________
13)
Are any of the owners, principal, officers, or key employees of this agency employed by, or do they possess an interest in, any of the following. YES NO Real Estate Sales (Brokerage, other) _________ _________ Real Estate Mortgage Broker Building or Construction Company Real Estate Developers Savings & Loan or Bank _________ _________ _________ _________ _________ _________ _________ _________
If yes, list the principal, name of company, the position the principal holds, and his or her percent of ownership interest. (Attach additional page if needed.) _______________________________________________________________________________________________ _______________________________________________________________________________________________ 14) Does the agency insure transaction in which the principal, principal's family or other officers have an interest? YES _________ NO _________ If yes, list all these projects, as well as the names of all entities under which this activity is conducted. (Attach additional page if needed.) _______________________________________________________________________________________________ _______________________________________________________________________________________________ 15) List outside business interest(s) of owners in related industries/or controlled business. List all customers from whom you obtain more than 10% of business and show percentage. _______________________________________________________________________________________________ _______________________________________________________________________________________________
16)
List the top four clients whom your firm regularly examines titles or closes real estate transactions. NAME OF FIRM CONTACT PERSON PHONE NO ______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ May we contact these clients? YES _________ NO _________ If no, please explain.
17)
Provide a minimum of three other professional references (firms that are not customers) for the agency. CONTACT PERSON PHONE NO _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ May we contact these reference(s)? YES _________ NO _________ If no, please explain.
********************************************************************************************* 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 for the Company, 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 UNDERSTAND that false, misleading, or omitted information in this application, resume, interview(s), and/or specifically on this form may disqualify the agency from its existing association with the Company. Also, I UNDERSTAND that false, misleading, or omitted information in this application, resume, interview(s), and/or on this form may result in the immediate termination of said association without notice. 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 the application
SIGNATURE: _________________________________________________
DATE: ____________________