(The date and time will be automatically entered in the order when sent)

I am ordering

Select Choice Title Insurance Written Title Search Only Verbal Title Search Only

With or Without Exceptions

With  Without

Purchaser Information

Name:        Select Choice Husband & Wife Joint Tenants Tenants in Common Single Other (if other)

Address:

City:                      State:             Zip:           

Present Owner

Name:        Select Choice Husband & Wife Joint Tenants Tenants in Common Single Other (if other)

Address:

City:                     State:              Zip:           

Lender Information

Name of Lender:                     Loan Officer:

Address:                     Phone:

City: ST: Zip:     Fax:

Name of Insured (if different from above)

Property Information

Select Choice Township of City of Village of  

County of:    *required

Property Street Address OR Legal Description *required

Tax Parcel Code   

Realtor Information: (if applicable)

Listing Agent's Name:             Listing Company:

Listing Agent's Phone:             Listing Agent's Fax:

Selling Agent's Name:             Selling Company:

Selling Agent's Phone:             Selling Agent's Fax:

Payment Information:

Charge:    Select Choice Listing Agent Lender Broker Selling Agent Seller

Please provide YOUR contact information:

Name
Institution
Work Phone
FAX
E-mail

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