RGTitleAgency.com

A full service insurance agency - celebrating our 50th year!

Peekskill (914) 739-2700                                     Poughkeepsie (845) 471-5511
Peekskill (800) 427-2567                                Poughkeepsie fax (845) 471-5542
Peekskill fax (914) 739-2808

PRINT THIS FORM - WHEN COMPLETED, FAX TO 914 739-2808

 

 

ORDER FORM

 

DATE:___________                 REISSUE OF #__________

 

APPLICANT: ________________________________________________

     

ADDRESS: _________________________PHONE/FAX:______________

 

FEE AMOUNT: $______________  MTGE AMOUNT: $_______________

 

PRIOR INSURANCE: FEE: $____________ MTGE: $_________________

 

WHEN:___________________BALANCE: $________________________

 

RECORD OWNER(S):__________________________________________

 

PREMISES:__________________________________________________

 

COUNTY:_______________________TOWN/VILLAGE:_______________

 

SECTION:____________ BLOCK:____________ LOT:_______________

 

PURCHASER(S):_____________________________________________

 

BANK:_____________________________________________________

 

BANK ATTORNEY:____________________________________________

 

ADDRESS: _________________________PHONE/FAX:______________

 

SELLER'S ATTORNEY:_________________________________________

 

ADDRESS: _________________________PHONE/FAX:______________

 

DEPARTMENTALS:___________ SURVEY INSPECTION:______________

 

SURVEY ENDORSEMENT:_________ BANKRUPTCY:_________________