Buyers Policy Order Form
Order Direct:
Toll Free: (800) 700-1191
Fax: (714) 800-4750
Note:
Bold
fields are required.
Order Date:
05/15/2008
Estimated Closing Date:
(mm/dd/yyyy)
Buyer/Proposed Insured Information:
Buyer:
Primary Contact:
Street Address:
City, State, Zip:
,
Phone Number:
Fax Number:
(Phone numbers must include 2 dashes ie. 555-555-5555)
Email Address:
Buyer's Counsel:
Phone:
Email Address:
Loan Information:
Purchase Amount: $
Amount of Insurance Requested: $
Seller's Information:
Seller's Legal Status or Entity:
Individual
Corporation
General Partnership
Limited Partnership
Limited Liability Company
Business Trust
Trust
Other
Main Pledgor of Collateral
(exact legal name, including dba, aka)
:
Street Address:
City, State, Zip:
,
Does the seller now or in the past 5 years done business in any other States
Yes
No
If yes, what states?
State of Legal Formation:
State of Seller's Place of Business
(if one place of business)
or Chief Executive Office
(if more than one place of business)
or State or Residence
(if individual)
:
Other States of Seller's Place of Business (during past 5 years):
Has the Seller been a party to a merger or has it acquired an operating business during the past 5 years?
Yes
No
During the past 4 months, has the Seller had any legal name(s)?
Yes
No
Are there additional Sellers involved?
Yes
No
If yes, please list additional Sellers below:
Seller Information:
Seller's Counsel:
Phone:
Email Address:
Comments:
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