Customer Information:
Name: (required)
Company:
Address
City:
State:	Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip:
Phone: (required)
Fax:
Email

Property Information:
Address: (required)
Tax Lot #:
Legal Description:
Lot:	Block:	Plat:
Vacant  Family (1-4)  Commercial/Ag.  Mobile Home
New Construction  First Mortgage  Second Mortgage

Parties to Transaction:
Seller 1:		SS#:
Seller 2:		SS#:
Buyer/Borrower 1:		SS#:
Buyer/Borrower 2:		SS#:

Products Requested:
Owners Policy:	Standard  Extended
Sale Amount:
Lenders Policy:	Standard  Extended  Smart
Loan Amount:
Leasehold Owners Policy:	Standard  Extended
Amount:
Leasehold Lenders Policy:	Standard  Extended
Loan Amount:
Closing At Fidelity Title?   Yes  No
Comments/Requirements:
Collection Account To Be Set Up At Fidelity Title?   Yes  No

Other Products:
Litigation Guarantee:	Amount of Coverage:
Subdivision Guarantee:
Chain of Title Guarantee:
Recorded Document Guarantee:
Lot Book Guarantee:

Copies To:
Name:
Company:
Address
City:
State:	Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Email
# Copies:
Name:
Company:
Address
City:
State:	Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Email
# Copies:
Name:
Company:
Address
City:
State:	Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Email
# Copies:
Name:
Company:
Address
City:
State:	Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip:
Phone:
Fax:
Email
# Copies: