TIS Abstractor Application

Abstractor Application

COMPANY INFORMATION

* Indicates required field

Name of Business *

Year Founded *

Owner Name *

First

Last

Main Contact, if different *

First

Last

Main Contact Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Is company incorporated? *

Incorporation Type *

Is your company part of a franchise? *

Referred by *

Phone Number *

Alternate Phone *

Fax Number *

License Type (if applicable) *

License Number (if applicable) *

State *

In the event the entity has additional licenses; please send additional information to vendors@c2ctitleservices.com

ABSTRACTOR INFORMATION

Since part of the criteria to determine assignments is 'Distance to Records', it is important that a physical mappable address, and not a PO Box, is included to ensure greater accuracy when assigning orders.

Name (as it appears on state license) *

Initial date of licensure (not including years as trainee) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

TIN/SSN *

Phone Number *

Alternate Number *

Email *

License Type (if applicable) *

License Number *

State *

In the event the entity has additional licenses; please send additional information to vendors@c2ctitleservices.com

E&O INFORMATION

Type *

Name of Insured *

Principal Address (1) *

Line 1

Line 2

City

State

Zip Code

Country

Names of Persons Covered *

Carrier Name *

Per Claim Limit ($) *

Aggregate Limit ($) *

Policy Expiry Date (mm/dd/yy) *

Policy Number *

Has a claim ever been filed against your current or prior E&O? *

If yes, by whom? Please provide details of disposition. *

Please describe event and outcome. *

Have you ever had ANY disciplinary action relating to your abstracting practice? *

Please attach relevant documentation. *

Max file size: 20MB

Have you ever had an application for licensure refused or denied by any state? *

BACKGROUND INFORMATION

How do you receive orders? *

Email Fax

What is your source of title? *

Plant County Records

If plant, name of plant(s): *

If applicable, is your license currently in good standing? *

If no, describe *

Have you ever had ANY disciplinary action relating to your abstracting practice? *

Failure to disclose Disciplinary Action will result in rejection of this application.

If yes, by whom? *

Date of Action: *

Type of Action(s): *

Have you ever had an application for licensure refused or denied by any state? *

Are you subject to any current or pending litigation? *

If yes, please provide details: *

Have you had any Claims/Judgements filed against you within the last five years? *

If yes, please provide details: *

Note: Submission of this application provides authorization for a360inc Title Services to perform a criminal record screening, when deemed necessary. a360inc Title Services absorbs all costs related to the Criminal Record Screen as such there is no cost to you.

DISCLAIMER AND SIGNATURE

By typing my name in the signature field below, I certify that my answers in this application are true and accurate to the best of my knowledge. I release and authorize a360inc Title Services to conduct a background check, including a search of public record and other relative information such as financial information, in order to verify the information which I provided as part of this application. If this application leads to a contract for services, I understand that providing false or misleading information in my application will result in my suspension from participating in the a360inc Title Services Abstractor Network and preclude me from receiving future orders. I further understand and agree that the purpose of this application is to become an independent contractor of a360inc Title Services and that nothing herein is intended to nor shall result in an employment relationship with a360inc Title Services.

Signature *

Date *

Submit

Abstractor Application

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