Application for Title Insurance:
Refinance Loan

This application is for lending institutions to complete and should be used in conjunction with first mortgage situations.

To ensure a prompt response, please make sure you fill out as many of the listed fields as possible. Your information will be kept confidential. We won’t sell, trade, or lease your information to anyone.

May we suggest that an “Authorization to Release Confidential Information” be submitted via fax or mail with this application. This form enables us to order payoffs and retrieve information for the closing.

*Name:
*Email:
*Property Owner
*Property Address:
Tax Key Number:
Legal Description:
*Lender:
Loan Officer:
*Proposed Insured:  Same     To read as follows:
*Loan Amount:
Loan Type:
Requested Endorsements:
*Anticipated Closing Date:
Property Type:  1 - 4 Family Residential
 Condo
 Land
 Commercial Property
 Other:
Prior Title Evidence:

 Pickup Abstract at:  or
I'll fax a copy of the old title insurance

Conditions of Title Known:
(Shared driveway, shared well, easements.)
Special Instructions:  Order City Letter
 Provide Current Tax Print-out
*Ordered By/Name & Co:
*Lender's Address:
*Phone:
*Fax:
*Required Fields  

Thank you for choosing Assurance Title, where our pledge to you is safety, certainty and confidence.