TITLE INSURANCE REQUEST FORM

Please complete only sections which are applicable to your Request.

REQUESTER'S INFORMATION

Name/Company:
Address:
Phone Number:
Fax Number:
Email Address:
Date Needed:
Requested Closing Date:
Note to Requester: After submitting this request, please submit the latest available Title Insurance Policy or Abstract of Title by:

Mail:         Carlson Koeck Kirk & Graves Ltd.

                   634 Water Street, P.O. Box 9

                   Prairie du Sac, WI 53578

Email:        titleinsurance@carlsonkoecklaw.com

Fax:           608.643.4691

SELLER INFORMATION

Name:
Address:

 
Phone Number:
Email Address:
Existing Mortgage Information: Lender:

Address:

Phone Number:

BUYER INFORMATION

Name:
Address:

 
Phone Number:
Email Address:

PARCEL INFORMATION

Property Address:
Parcel Number:
Brief Legal Description:

 
Sale Price:
Property Type (use):

LENDER INFORMATION

Name:
Contact Person:
Address:

 
Phone Number:
Fax Number:
Email Address:
Loan Amount:

COMMITMENT INFORMATION

Endorsements:   GAP          Location

  ARM           Other:_____________________

  G Condominium
Draft Deed and Transfer Return:  
Yes   No

REALTOR/ATTORNEY INFORMATION

Seller's Broker/Agent:
Address:

 
Phone Number:
Fax Number:
Email Address:

 

Buyer's Broker/Agent:
Address:

 
Phone Number:
Fax Number:
Email Address:

 

Seller's Attorney:
Address:

 
Phone Number:
Fax Number:
Email Address:

 

Buyer's Attorney:
Address:

 
Phone Number:
Fax Number:
Email Address:
 
       PLEASE NOTE:

Submission of this form does NOT create an Attorney-Client relationship between you and the Firm or an Attorney of the Firm.  An Attorney-Client relationship is established only by expressed actions of an Attorney of the Firm and a client.

 

Privileged information should NOT be submitted with this form.

 
       The Attorneys in the Firm are licensed to practice law only in the State of Wisconsin.
The Firm reserves the right to accept or reject any request for any reason including real or  perceived violations of the Wisconsin Rules of Professional Conduct, Code of Ethics, or
Firm policies.
      

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