ࡱ>  JrbjbjVV 4<<V# ff8t<f 0====L"!;;;;;;;>@;%LL%%;==g<B*B*B*%:==;B*%;B*B*N6L9=`%80;}<0<8A'4A`L9AL9<2"P#B*$$2"2"2";;B*2"2"2"<%%%%A2"2"2"2"2"2"2"2"2"f o: FORM RA-10 STATE OF ILLINOIS (DFI-Rev.11/10-Pg.1) DIVISION OF FINANCIAL INSTITUTIONS TITLE INSURANCE SECTION TITLE INSURANCE ACT APPLICATION FOR REGISTRATION OF A TITLE INSURANCE AGENT (Pursuant to Section 16 of the Title Insurance Act) (ALL INFORMATION MUST BE TYPEWRITTEN) (Incomplete Applications will be returned) (DFI USE ONLY: AGENT NUMBER ______________ ) DATE OF APPLICATION:  FORMTEXT       NAME OF AGENT:  FORMTEXT       ADDRESS: (NO POST OFFICE BOX) FORMTEXT       SUITE NO. FORMTEXT       CITY, STATE, ZIP CODE:  FORMTEXT       PHONE NUMBER (INCLUDING AREA CODE):  FORMTEXT       FAX NUMBER:  FORMTEXT       E-MAIL ADDRESS:  FORMTEXT       CONTACT PERSON, NAME AND TITLE:  FORMTEXT       BRANCH OFFICES, IF ANY:  FORMTEXT       TYPE OF ENTITY: CORPORATION (1)  FORMCHECKBOX  PARTNERSHIP (2)  FORMCHECKBOX  INDIVIDUAL (3)  FORMCHECKBOX  LIMITED LIABILITY COMPANY (4) FORMCHECKBOX  ASSOCIATION (5)  FORMCHECKBOX  OTHER (6)  FORMCHECKBOX  If Corporation, list below all Officers with their titles, Directors and Shareholders, showing the percentage of ownership (other than Public Corporations). In addition, attach a copy of the Certificate of Incorporation or Authorization to do business in Illinois issued by the Illinois Secretary of State. If Partnership, list below all Partners, showing percentage and type of partner. If Individual, list birthdate below. (4) If Limited Liability Company, list all managers and members with their percentage of ownership. In addition, attach a copy of the Certificate of Organization or Authorization to do business in Illinois issued by the Illinois Secretary of State. (5) If Association, list below all Officers with their titles, Directors and Members, showing percentage of ownership. (6) If other, describe below, in detail, type of entity and controlling parties as applicable.  FORMTEXT       (Use Page 2 of Application if more space is needed.) Page 1 of 6 FORM RA-10 STATE OF ILLINOIS (DFI-Rev.11/10-Pg.2) DIVISION OF FINANCIAL INSTITUTIONS TITLE INSURANCE SECTION TITLE INSURANCE ACT APPLICATION FOR REGISTRATION OF A TITLE INSURANCE AGENT (Pursuant to Section 16 of the Title Insurance Act)  FORMTEXT       MATERIAL FACTS 1. Is the Agent currently registered as an Agent by any other Title Insurance Company in Illinois?  FORMTEXT       If yes, name (s) of Title Insurance Company or Companies.  FORMTEXT       2. Has Agent or any of its officers, directors, members, partners or shareholders previously been a registered agent, or an officer, director, member, partner or shareholder of a registered agent, where the agency agreement was terminated? FORMTEXT       If yes, name (s) registered under and name (s) of Title Insurance Company.  FORMTEXT       3. Has Agent or any of its officers, directors, members, partners or shareholders (other than Public Corporations) ever been the subject of disciplinary action by this Department or any other regulator of Title Insurance business?  FORMTEXT       If yes, please explain on separate attachment. Page 2 of 6 FORM RA-10 STATE OF ILLINOIS (DFI-Rev.11/10-Pg.3) DIVISION OF FINANCIAL INSTITUTIONS TITLE INSURANCE SECTION TITLE INSURANCE ACT APPLICATION FOR REGISTRATION OF A TITLE INSURANCE AGENT (Pursuant to Section 16 of the Title Insurance Act) Agent is authorized by the registering title insurer to perform the following:  FORMCHECKBOX  Determine insurability of title  FORMCHECKBOX  Act as an escrow agent pursuant to subsections (f), (g), and (h) of Section 16 of the ITIA  FORMCHECKBOX  Solicit title insurance  FORMCHECKBOX  Collect premiums  FORMCHECKBOX  Issue title insurance commitments, policies and endorsements Are any services contracted out? If so, which ones?  FORMCHECKBOX  Title search  FORMCHECKBOX  Typing of commitment  FORMCHECKBOX  Typing of policy  FORMCHECKBOX  Escrow Services NOTE: All except #5A require written contracts which must be attached AND include a description of the process below.  FORMTEXT       Page 3 of 6 FORM RA-10 STATE OF ILLINOIS (DFI-Rev.11/10-Pg.4) DIVISION OF FINANCIAL INSTITUTIONS TITLE INSURANCE SECTION TITLE INSURANCE ACT APPLICATION FOR REGISTRATION OF A TITLE INSURANCE AGENT (Pursuant to Section 16 of the Title Insurance Act) STATE OF ILLINOIS ) ) ss COUNTY OF  FORMTEXT       ) AFFIDAVIT OF TITLE INSURANCE AGENT  FORMTEXT       being duly sworn states on oath: (Person Making Affidavit) I am authorized to make this affidavit on behalf of  FORMTEXT       ( Agent ) . (Name of Agent) The Agent agrees to conduct itself, at all times, in full compliance with the Title Insurance Act and the Rules and Regulations promulgated thereunder. 3. Agent agrees to notify registering title insurance company promptly of changes to Agents contact information and entity structure. 4.. All information contained in this application is true and correct.  FORMTEXT       Subscribed and sworn to before me this FORMTEXT      day of  FORMTEXT      ,  FORMTEXT      .  FORMTEXT       My commission expires  FORMTEXT       (Notary Public) Page 4 of 6 FORM RA-10 ENOPQRa G H I u   0 2 ¹®xfb\Rjh`rCJU hCJh"jhW CJUaJmHnHujhW CJUaJhW CJaJjhW CJUaJh.CJaJh:hCJaJh:h:CJaJh:5CJaJh:h:5CJaJh15>*CJh5>*CJ hJcCJ hCJ h:9CJ hjCJ h5CJE  I t u    X Z P R \ ^ $a$2 F H J T V ( * > @ B L N   ͣ͆yljh`rCJUjFh`rCJUjh`rCJUjhD-CJUmHnHuj^h`rCJU h -DCJjhCJUjh`rCJU hD-CJ hCJjhCJUjh`rCJUjvh`rCJU hWCJ*  4 6 J L N X Z      " > B F f h 괧􍇁{nꇴjh`rCJU hWCJ h3CJ hH7`CJhjhH7`5CJjhLCJUmHnHujh`rCJU hLCJjh`rCJUjhD-CJUmHnHuj.h`rCJU hD-CJjh`rCJU hCJ haCJ'^ " &'LMHIBDlnpgdE$a$ $h^h`a$$a$ & F & F$ & Fa$gdH7` 78FGHIK^_mnowMHBDFZ\^hjr֜蒅u蒜o hj+CJjhECJUmHnHujDh`rCJU hECJh hCJjh`rCJUj\h`rCJUjh`rCJUjth`rCJU hH7`CJ h3CJ hLCJjh`rCJUjh`rCJU+pr"RT|~VX$a$TzVXZnpr|~*.*ƹ̩Ơ񜘜}okkh*0%jhPUmHnHuj.h`rUhPjh`rUh`;hRihhD-5>*CJjhWCJUmHnHujh`rCJU hWCJjh`rCJUh5>*CJ hjCJ h:9CJ hCJ h5CJ h15CJ(.0XZ\^`bdf.0246$a$$a$*,02FHJTVZfFH\^`jln *,06 *,J\ſŌņzs h5CJ hj+CJ huCJ hWCJ h! 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" ""D"X"Z"^"" ###ż۵۩۵園oiici\VPV h:9CJ hQCJ hQ5CJ hj+CJ huCJjhCJUmHnHujh`rCJU hCJjh`rCJU hjCJ h15CJhuh' 5>*CJ hj5CJhj5>*CJhjh' 5>*CJhuh' 5CJh' h' 5CJ h' CJh' h' 5>*CJh' 5>*CJ("*","."0"2"4"6"8":"<">"@"B"D"\""#####$T$$$$gdI $a$gdQgdQ$a$gdu# #B####$$$$$"%$%8%:%<%F%H%P%T%V%Z%%%%%%%%%%% &&&&&µȥ疟Ȋ}mga h:CJ hKLCJjh{)CJUmHnHujh`rCJU h{)CJ huCJh5>*CJ hCJjh5CJUmHnHujh`rCJU h5CJjh`rCJU h'jCJ h!CJhQ5>*CJ hI CJ hQ5CJ hQCJ hJcCJ$$$$$$$%T%V%X%Z%%%%&B&D&& '"')(*(($h^h`a$gd$a$gdm:$ & F a$gd"Q & F $a$$a$gdugdI &&&&&&&&' '"')((((((((() )))* * *\*^*r*t*v************¼¶¶輝藊zmzj`h`rCJUjhY CJUmHnHujh`rCJU hY CJjth`rCJU huCJ hG3CJ hm:CJ h:CJ hCJh"Qh"Q>*CJ h"QCJjh:CJUmHnHujh`rCJUjh`rCJU*(()))*****+++++++++++++++++ ^`gdm:$a$$a$**********++ +++4+`+b+v+x+z++++++++++,XzXXX㞑zsmgasz_zY h:9CJU hj+CJ huCJ h"QCJ hu5CJ h5CJjh5CJUmHnHujh`rCJU h5CJjhCJUmHnHujLh`rCJU hCJ hCJ hPCJjhY CJUmHnHujh`rCJUjh`rCJU hY CJ"++zXY8Y:YbYdYYYZ@ZZZZZ>[@[[[<\>\f\h\j\\gdI $a$ ^`gdm: STATE OF ILLINOIS (DFI-Rev.11/10-Pg.5) DIVISION OF FINANCIAL INSTITUTIONS TITLE INSURANCE SECTION TITLE INSURANCE ACT APPLICATION FOR REGISTRATION OF A TITLE INSURANCE AGENT (Pursuant to Section 16 of the Title Insurance Act) NAME OF TITLE INSURANCE COMPANY:  FORMTEXT       ADDRESS:  FORMTEXT       CITY, STATE, ZIP CODE:  FORMTEXT       PHONE NUMBER (INCLUDING AREA CODE):  FORMTEXT       NAME AND TITLE OF PERSON TO CONTACT WITH REGARD TO THIS APPLICATION:  FORMTEXT       STATE OF ILLINOIS ) ) ss COUNTY OF  FORMTEXT       ) AFFIDAVIT OF TITLE INSURANCE COMPANY  FORMTEXT       being duly sworn states on oath: (Name of Person) I am authorized to make this affidavit on behalf of  FORMTEXT       ( Company ) . (Name of Title Insurance Company) The Company understands and agrees that it is responsible for keeping the Agent informed about the Illinois Title Insurance Act, the Rules and Regulations promulgated thereunder and all forms prescribed by the Director. The Company agrees to notify DFI of changes in Agent s contact information and entity structure. The attached is a true and correct copy of the Agency Contract/Agreement. The Company knows of no reason why the Agent should not be registered.  FORMTEXT       Subscribed and sworn to before me this  FORMTEXT       day of  FORMTEXT      ,  FORMTEXT      .  FORMTEXT       My commission expires  FORMTEXT       Page 5 of 6 FORM PR-30 STATE OF ILLINOIS (DFI-Rev.11/10-Pg. 6) DIVISION OF FINANCIAL INSTITUTIONS TITLE INSURANCE SECTION TITLE INSURANCE ACT REPORT OF PRODUCERS OF TITLE BUSINESS AND ASSOCIATES (Pursuant to Section 18 of the Title Insurance Act) (ALL INFORMATION MUST BE TYPEWRITTEN) Date of Report 12/10/2010  FORMTEXT       (Name of Title Insurance Agent) 1. The Agent is: (a)  FORMCHECKBOX  an individual or (b)  FORMCHECKBOX  a firm, partnership, association, corporation or other legal entity. 2. The Agent: (a)  FORMCHECKBOX  is or  FORMCHECKBOX  is not engaged in Illinois in the trade, business, occupation or profession of buying or selling interests in real property; and (b)  FORMCHECKBOX  is or  FORMCHECKBOX  is not engaged in Illinois in the trade, business, occupation or profession of making loans secured by interests in real property; and (c)  FORMCHECKBOX  is or  FORMCHECKBOX  is not engaged in Illinois in the trade, business, occupation or profession of acting as a broker, agent, attorney, or representative of natural persons or other legal entities that buy or sell interests in real property or that lend money with such interests as security. 3. If the answer to Question 1 is (b) the following is a true and complete list of all entities or persons known, or reasonably believed by Agent, to be an  associate of a  producer of title business as defined in the Illinois Title Insurance Act. 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