1. Name of Agency ________________________________________________________________
2. Business Address ________________________________________________________________
3. City, State, Zip ________________________________________________________________
4. Telephone ________________ Fax ________________ Email ______________________
5. Current Status _____ Existing Agency _____ New Agency being established
6. Active in the following counties ____________________________________________________
7. Agency is a ____ Sole Proprietorship ____ Corporation ____LLC

____ General Partnership ____ Limited Partnership ____LLP

____ Other________________________________________________________

8. List all title insurance underwriters or title companies with whom you are an active agent or affiliated, including number of years.

_______________________________________________________________________________

9. List all title insurance underwriters with whom you are no longer active, including number of years as agent.

10. Has an underwriter ever cancelled you? ____ Yes ____ No If yes, then provide details.

(Please furnish a copy of your E&O declaration page and evidence of title insurance of title agent coverage or endorsement.)

12. Are you employed by or have an ownership interest in any of the following? If yes, list the name of the company and percent of ownership interest.

Attorney Information (To be completed by each attorney, where applicable)

	Name ______________________________________________ Date of Birth _____________________
	Current Home Address ___________________________________________________________________
	City, State, Zip _____________________________________________ Telephone ___________________
	Social Security Number ______________________________ Bar Code Number ___________________
	Drivers License Number __________________________________ State ______________________
	Are you currently authorized to practice law in the state of Illinois? ___ No ___Yes Year Admitted_____
	Percent of time practicing law: _____________%
	Percent of practice involving real estate and title law: _____________%
	Percent of practice in examination and searching real estate title: _____________%
	List three business references that know your business reputation:

I AUTHORIZE Chicago Title Insurance Company (the Company) to obtain a "consumer report" and\or "investigative consumer report" or other background information used in connection with consideration of my application for appointment as a title agent or at any time in the future in connection with the review of my status as a title agent. I release the Company and its partners, stockholders, officers, directors, agents, employees and affiliates from any and all liability for damages of whatever kind which may arise from or relate to any "consumer report" and\or "investigative consumer report" or other background information requested, obtained, or used by the Company in connection with my application for such appointment or in connection with any future review of my status as a title agent.

I UNDERSTAND the above and certify that the application information stated herein by me is true, correct, and complete to the best of my knowledge.

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Last modified: January 28, 2010