Title Insurance Order Form

Residential Title Application

Ordering title insurance products is easy! Just fill in the following information and your request for title insurance services will
be transmitted to Old Republic Title’s customer service desk. If you have any questions or need additional information call
612.371.1111 or 800.328.4441. You may FAX orders to us 612.435.9737.
Thank you for placing your order with Old Republic National Title Insurance Company.

*Indicates required fields
General Information
Purchase/Refinance*
Owner's Policy Amount
Name of Insured
Lender's Policy Amount
Name of Insured
Junior Mortgage Amount
Name of Insured
Junior Mortgage Amount
Name of Insured
Junior Mortgage Amount
Name of Insured
Additional Services
Special Assessment Search	Yes No
Plat Drawing	Yes No
Priority Pictures	Yes No
Closing at Old Republic Title	Yes No
Closing Date
Property Information
Property Address:
City:
County:
State:
Zip:
Property ID Number
Legal Description:
Property Type
	Abstract Torrens
Torrens Certificate Number
Buyer or Borrower
Name:
Name:
Current Address: (if other than property address)
City:
State:
Zip:
Phone:
Phone:
Seller Information:
Seller's Name
Current Address: (if other than property address)
City:
State:
Zip:
Phone:
Buyer's Agent
Name:
Company:
Phone:
Seller's Agent
Name:
Company:
Phone:
Refinance Payoff Information
Name:
Loan #:
Phone:
Refinance Payoff Information (2)
Name:
Loan #:
Phone:
Customer Information
Lender Name
Address:
City:
State
Zip Code:
Contact Name*
Phone:
E-mail*

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