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					           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                 *Association              *Corporate/Partnership
                                 *LLC                               *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 _____________________________              Tax ID #_______________

2)     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.

9)    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)   Do you close real estate transactions? ________________________ Average per month? _______________________

11)   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     _________NO       Do you carry E&O Insurance?
      _________ YES     _________NO       Do you carry Fidelity Bond?
      _________ YES     _________NO       Do you carry Professional Liability (Atty/Law firm only)?
      _________ YES     _________NO       Are all premiums fully paid? If not, explain. OR
      _________ YES     _________NO       Are premiums financed? _________YES _________NO Monthly?
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: ____________________

				
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