Old Republic National Title Insurance Company

Application For Approved Attorney

Return Completed Application to Shayna Best via FAX (610) 687-6056
General
1. Name:
Social Security Number:
Firm Name:
Address
Address (cont.)
City:
State:
Zip Code:
Phone / FAX
E-mail Address
2. Date firm commenced business:
3. Date of applicant's admission to bar:
4. List of other state jurisdictions and dates admitted to bar:

Business / Customer
5. Percentage of practice devoted to real estate:%
6. How many years experience in real property/conveyancing law does applicant possess?
7. Are all searches/abstracts performed by an attorney in the firm? Yes  No
Please list all attorneys in form who perform searches/abstracts:

8. If searches/abstracts are not performed by an attorney in your firm, please list by whom they are performed and whether by an attorney

9. Please list all lenders for whom you supply title evidence, title insurance, or conduct closings:

10.

Are you presently a policy-writing agent or approved attorney for any other title insurance company:

Yes  No
If yes, please list

11.

Were you previously an agent or approved attorney for any underwriters not listed in question 10 above?  Yes  No
If yes, please list the company and explain the reason why the relationship was terminated.

12 Over the next 12 months, Agent anticipates:
Net remittances to all title insurance underwriters  $
Proposed net remittances to Old Republic National Title Insurance Company  $
During the past two calendar years, the following was the approximate annual net remittance to all underwriters:
20 $
19 $
13. What volume of title orders anticipated to be submitted
monthly    annually
Insurance Coverage
14. Please provide the following information concerning insurance coverage. Supply copies of policies in effect. If no insurance in place, please so state.
Professional liability carrier:
Coverage Limit Each Claim:$   Aggregate: $
Deductible: $   Expiration Date:
Fidelity/Surety Insurance Carrier 
Coverage Limit Each Claim: $   Aggregate: $
Deductible: $   Expiration Date:
15.

Have you or any other firm members been, or are you now, the subject of any disciplinary proceedings by any bar organization?

Yes  No
If yes, please explain:

16. Please list all losses, if any, which you or any of your insurers have paid or incurred in the last three years for you or any member or employee of your firm (Please attach sheet explaining each specific matter):

20  

20  

19  

17. If applicant performs closings, maintains escrow/trust accounts, or disburses construction funds, complete Presigning Escrow Audit Procedure/Questionnaire, Exhibit 1.
References:
Attorney's Name
Firm:
Address:
City:
State:
Zip Code:
Phone:
Attorney's Name
Firm:
Address:
City:
State:
Zip Code:
Phone:

It is agreed and understood that in consideration of the Applicant's application for appointment as an Approved Attorney, Old Republic Title may seek further information relative to Applicant's business and professional reputation in the community and Applicant's credit history.  This may include matters in the nature of an investigative consumer report as defined in the Federal Fair Credit Reporting Act.  This notice is given to you in compliance with said Act.  It is further understood and agreed that the information set forth herein may be verified and investigated by Old Republic Title, but is furnished on a confidential basis by the Applicant to aid Old Republic Title in its investigation and determination of the qualifications of the Applicant. 

The Applicant further agrees to promptly contact Old Republic Title in the future if circumstances change and the Applicant's answers to the questions above are no longer accurately reflected by this application.  Applicant further acknowledges that Old Republic Title has the right to request that Applicant periodically complete other applications in the future so that our files and records will accurately reflect the Applicant's actual status at that time. 

The Applicant further acknowledges that this application has been executed and sworn to under the pains and penalties of perjury.

Applicant:   Date:

Signed: