Date: __________________
OWNER POLICY REJECTION FORM
Pursuant to requirement of §2704.051 and §2704.052, Insurance Code, and Procedural Rule P-65, the undersigned hereby acknowledge that a Loan Policy is to be issued in File No. _______________ in consideration of $______________ premium to the lender and that such policy does not afford title insurance coverage to the undersigned in the event of a defect in the title to the real estate which is being acquired. An Owner’s Policy in the amount of $___________________ shall be issued for an additional premium of $___________________ unless rejected hereby.
The undersigned hereby reject the issuance of said Owner’s Policy
_____________________________
_____________________________
[ACKNOWLEDGMENT]
No guidelines are available for this form at this time.