Customer For Title Only

Instructions: Please complete all blanks under "Client Information." Please also fill in as much information as possible under "Policy Information."

Additionally, orders may be faxed to 928-753-6339. If you have any questions, please feel free to contact our order desk at 928-753-6300 or send email to orderdesk@statetitleagency.com.

Client Information

Date:

City/Branch:

Customer:

Company:

Address:

City:

State:

Postal Code:

Phone #:

Fax:

Cell Phone:

Email:

Policy Information

Please Check All That Apply

Order No.:

Title Now In:

Insured Buyer:

Parcel Number:

Type of Owner Policy

Standard

Home Owners

ALTA Residential

Owner Policy Liability Amount: $

Insured Lender:

Type of Lender Policy:

Lender Policy Liability Amount: $

Type of Property:

Residential

Vacant Land

Commercial

Proposed

Existing

Send Report To:

Phone:

Fax:

Legal Description

Plant Information:

Other Information

If the person submitting this form is not the client, please supply your name and email address below so that a State Title Representative is able to contact you regarding this inquiry.

Name:

Email:

Please provide any additional information that may help us in processing your request.

Submit to State Title

In the box labeled 'Security Code', please enter the garbled text that appears in the image below. This helps us ensure that your request is genuine and not an engineered attack on our website.

Security Code: