STEWART TITLE GUARANTY COMPANY
STEWART TITLE GUARANTY COMPANY
APPLICATION FOR APPOINTMENT AS A TITLE INSURANCE POLICY ISSUING AGENCY
PART I –AGENCY INFORMATION
TO BE COMPLETED AND SUBMITTED BY CORPORATE PRESIDENT, GENERAL PARTNER, MANAGING PARTNER OR
SOLE PROPRIETOR (WHICHEVER IS APPLICABLE)
*(SECTIONS LEFT BLANK MAY RESULT IN REJECTION OF THE APPLICATION)*
|1. LEGAL NAME OF AGENCY: |
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|2. AGENCY’S D/B/A, IF ANY |
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|3. NAME OF INDIVIDUAL COMPLETEING APPLICATION: |4. POSITION/TITLE WITH AGENCY: |
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|5. The Agency is a CORPORATION PARTNERSHIP SOLE PROPRIETORSHIP LLC LLP |
|herein referred to as the APPLICANT, desiring appointment by STEWART TITLE GUARANTY COMPANY, herein referred to as Stewart, as a title insurance policy issuing |
|Agency, submits for Stewart’s consideration the following information. PLEASE LIST ALL THAT APPLY: |
|6. Is this Agency an Affiliated Business Arrangement (AfBA)? Yes No If Yes, please list Members associated with AfBA. |
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|7. Agency Street address |(Suite) |
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|(City) |(State) |(Zip) |
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|8. Agency mailing address (if different from Street address) |(Suite) |
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|(City) |(State) |(Zip) |
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|9. Main telephone number |10. Fax number |11. Agency E-Mail address |12. Agency Website: |
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|13. Do any veterans, women or minorities own an interest in this business? Yes No |14. Please designate languages spoken by Agency |
|If yes, please designate: % of ownership: |personnel: |
|*Please attach copy of minority ownership certification. | |
|15. Primary Ethnic Market Served (Optional) |16. Year agency was established: |17. Federal Tax identification: |
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|18. Total number of full time employees, including branches: |19. Prior name, if any, of agency |
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|20. Prior address of agency (for last 10 years): |
|Street Address |City |State |Zip |Years at location |
| | | | |From: |
| | | | |To: |
| | | | |From: |
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|21. Has agency ever filed bankruptcy? YES NO If yes, include date, court, case number, disposition and explanation below: |
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|22. Has the applicant agency or any of its principals, officers or employees ever been charged/convicted of any criminal activity? |
|YES NO If yes, please attach explanation. |
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|23. Has the applicant agency, or any of its principals, officers or employees ever been the subject of any regulatory action by any governmental body for any |
|real estate or escrow related activity? YES NO If Yes, please explain below. |
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|24. OWNERS OR PARTNERS OF 10% OR MORE OF AGENCY |
|Full Name |Home Address, Street, City, Zip Code |Job Title |Ownership |Full Time |
|(including maiden name, if any) | | |Interest % |Employee |
|1. | | | | Yes |
| | | | |No |
|2. | | | | Yes |
| | | | |No |
|3. | | | | Yes |
| | | | |No |
|4. | | | | Yes |
| | | | |No |
|5. | | | | Yes |
| | | | |No |
* If total is less than 100%, please explain
|25. ALL TITLE INSURANCE UNDERWRITERS REPRESENTED, CURRENT OR PAST |Relationship |Year |Year |
| |Exclusive? |Signed |Canceled |
|1. | Yes | | |
| |No | | |
|2. | Yes | | |
| |No | | |
|3. | Yes | | |
| |No | | |
|4. | Yes | | |
| |No | | |
|5. | Yes | | |
| |No | | |
|26. Has agency ever applied to any Stewart underwriter previously? Yes No |
|If yes, please provide details below: |
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|27. If agency relationship with any underwriter has ever been terminated for any reason, including mutual agreement, please explain circumstances below: |
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|CLAIMS/LITIGATION (INCLUDING ATTORNEYS FEES AND EXPENSES) |
|28. List all claims (escrow and title) paid by the agency or title insurance underwriters (for applicant claims), by date, total amount & reason for past five |
|years. Explain in detail the five largest claims paid during the past five years. |
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|29. List the amount of claims paid pertaining to question (28) in which agency paid? |
|List the amount of claims by which underwriter paid? |
|Please explain further below: |
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|30. Is the agency currently (or anticipated to be) a plaintiff or defendant in any litigation? YES NO If Yes, please include date, court, case number, |
|disposition and explanation. |
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|31. How many lawsuits has the agency been a party to over the past five years, other than those listed in question (30)? Explain each, including |
|resolution, and attach a copy of last pleadings. If None, please skip question. |
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|32. Does agency have any current judgments or liens filed against it? YES NO If yes, please explain below. |
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CERTIFICATION
By submitting this application, I certify that I have the authority to represent that the information provided or statements made above or on any attachment(s) are true and correct. I understand that the information and/or statements shall be used to determine The Agency’s eligibility for appointment as an Agency of Stewart Title Guaranty Company and/or its affiliates.
I understand that any misleading or false information furnished by Applicant shall constitute grounds for immediate termination of any agreement entered into between Applicant and Stewart Title Guaranty Company or any affiliated entity of Stewart. My submitting the application on behalf of Applicant does hereby further represent that I have has the authority to bind Applicant.
| |DATE: |
|NAME OF AGENCY/APPLICANT | |
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|BY: _____________________________________________________ |NAME: |
|(Signature) |(Please Print) |
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|POSITION OR TITLE: | |
STEWART TITLE GUARANTY COMPANY
APPLICATION FOR APPOINTMENT AS A TITLE INSURANCE POLICY ISSUING AGENCY OR APPROVED ATTORNEY
PART II – INDIVIDUAL APPLICATION (Attorneys must also complete Attorneys Section)
TO BE COMPLETED AND SUBMITTED BY PARTNER, ATTORNEY, OFFICER, DIRECTOR, BRANCH MANAGER, AUTHORIZED SIGNATORY
*(SECTIONS LEFT BLANK MAY RESULT IN REJECTION OF THE APPLICATION)*
|1. Legal Name of Agency |
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|2. Full Name (last, first, middle and maiden) Please spell out. |3. Position with agency |
| Male Female | |
|4. Residence addresses (last 10 years) |
|Residence Street Address |City |State |Zip |Years at Residence |
| | | | |From: |
| | | | |To: |
| | | | |From: |
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|5. Home telephone number |6. Cell Phone Number |7. Driver’s license (State, Number) |8. Birthdate |9. Social Security Number |
| | |State DL # | | |
|10. Business Address (if different from Agency address) |
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|11. Business telephone number |12. Fax number |13. E-Mail address |
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|14. Have you filed any business or personal bankruptcy? YES NO |
|If yes, include date, court, case number, disposition, copy of filing and discharge. |
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|15. Are there any outstanding (or anticipated to be) judgments or involuntary liens against you? YES NO |
|If yes, please explain below. If None, please skip question. |
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|16. Have you ever been charged/convicted of any crime (including driving under the influence)? YES NO |
|If yes, give date, city county, state, charge, disposition and explanation. |
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|17. Have you ever been turned down for a fidelity bond? YES NO If Yes, please explain below. |
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|19. To what Professional Associations do you belong? |
|20. Name of spouse (including maiden name, if any), employer & occupation. |21. Spouses employer & occupation. |
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|22. EDUCATION |
|State in chronological order each High School, College, University or Post Graduate School Attended |
| |Location |Year Attended |Date Graduated/Decree |
|Name of Institution | | | |
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|23. EMPLOYMENT HISTORY (LAST 10 YEARS BEGINNING WITH MOST RECENT EMPLOYMENT) |
|DATES |NAME AND ADDRESS OF EMPLOYER |SUPERVISOR & PHONE NO. |POSITION/DESCRIPTION OF JOB |
|FROM | | | |
|TO | | | |
|FROM | | | |
|TO | | | |
|FROM | | | |
|TO | | | |
|24. List at least four (4) references, outside of your firm or agency, including two banks or trade references, having personal knowledge of your character and|
|professional reputation. |
|COMPANY ADDRESS (Street, City, State, Zip) CONTACT PHONE NO. |
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AGREEMENT TO ALLOW BACKGROUND INVESTIGATIONS, ETC.
I understand that Stewart may verify and exchange information regarding this application and subsequent contractual agreements, including, but not limited to, requesting investigative consumer reports, records of criminal convictions and/or credit reports. I also understand that Stewart may contact these sources to update information at any time without further notice to me, my firm or agency. Upon written request to Stewart, I may obtain additional information about these reports under the requirements of the Fair Credit Reporting Act. I understand and agree that Stewart may engage other parties to conduct the investigation authorized by this agreement.
CERTIFICATION
By submitting this application, I certify that the information provided by Applicant or statements made above or on any attachment(s) to my statements are true and correct. I understand that the information and/or statements shall be used to determine my firm or agency’s eligibility and my personal eligibility for appointment as an Agency of Stewart Title Guaranty Company and/or its affiliates. I understand that any misleading or false information furnished by or pertinent information omitted by myself shall constitute grounds for immediate termination of any agreement entered into between applicant and/or myself and Stewart and any affiliate.
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|(Signature) |Name (PRINTED) and DATE |
STEWART TITLE GUARANTY COMPANY
APPLICATION FOR APPOINTMENT AS A TITLE INSURANCE POLICY ISSUING AGENCY
ATTORNEY INFORMATION
(Each Owner, Officer, or Employee Who is an Attorney is to Complete this Attorney Information in Addition to Part II-Individual)
(SECTIONS LEFT BLANK WILL RESULT IN REJECTION OF THE APPLICATION)
|1. LEGAL NAME OF AGENCY. |
|2. Full Name (last, first, middle and maiden) |3. Business Address (Street, City, State, Zip) |
|4. Each state in which you are admitted to the bar, bar number, and year admitted. |5. How long have you practiced in current firm or partnership? |
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|6. Are you a member of any law firm or partnership other than the agency? If so, what is name, address and telephone number? |
|Name |Address (Street, City, State, Zip) |Telephone Number |
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|7. What was your previous firm or partnership and how long did you practice there? Please list for past 10 years)? |
|Firm/Partnership |Address |Years |
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|8. Have you or your insurer ever paid a claim for negligence, malpractice, error & omission, etc. YES NO If yes, please explain below: |
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| ATTORNEY’S PROFESSIONAL LIABILITY POLICY (ATTACH COPIES) |
|9. Are you or your firm currently under investigation or have you or your firm ever been the subject of any disciplinary action by any state or federal bar or |
|court, etc.? YES NO If yes, please explain below: |
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|10. Are you an approved attorney for any underwriter? YES NO If Yes, please list: |
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LYNN W. WILBURN INVESTIGATIONS, INC.
Dear Applicant:
Stewart Title Guaranty Company has retained Lynn W. Wilburn Investigations, Inc. to perform a background investigation on you pursuant to your application to Stewart to become an Agency, approved attorney and/or employee. The background investigation includes, but is not limited to a consumer credit report.
The Fair Credit Reporting Act (FCRA) requires that you be notified prior to our obtaining your consumer credit report. You are hereby notified that a copy of your consumer credit report will be obtained. No further action concerning your application can be completed until this office receives the acknowledgement.
Lynn W. Wilburn Investigations, Inc. has notified me that a copy of my consumer credit report will be obtained pursuant to my application submitted to Stewart Title Guaranty Company.
I have read this authorization and hereby authorize Lynn W. Wilburn Investigations, Inc. to conduct a background investigation on me pursuant to my application to Stewart Title Guaranty Company and/or its affiliates. I understand that the investigation shall include but not be limited to accessing my credit history.
______________________
Printed Name Applicant’s Signature Date
______________________
Printed Name Applicant’s Signature Date
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