TX Proof of Loss 1997

TEXAS TITLE INSURANCE PROOF OF LOSS FORM

Please complete all items to the best of your knowledge and return this form to us within 91 days. We will use the form to determine if your loss is covered under the policy.

NOTE: DELAY IN RETURN OF THIS FORM MAY AFFECT OUR ABILITY TO PROMPTLY PROCESS YOUR CLAIM

FOR INFORMATION OR TO SUBMIT A CLAIM, CALL 1-800- _______________.

1)Name of Insured(s):

Address of Insured(s):

Telephone Number of Insured(s)

2)Your interest in the Property:

____ OWNER ____ MORTGAGEE ____ OTHER (if Other, please explain)

3) Please complete the following to the best of your knowledge OR attach a copy of your policy:

a) Date the policy was issued, if known:

b) Policy number, if known:

c) File or GF number, if known:

d) Name of issuing agent, if known:

e) Legal description of the property (see deed or title insurance policy):

f) Street address of property:

Failure to provide enough information for us to identify your policy may result in a delay in processing your claim or denial of your claim.

4) Please describe the problem you believe affects the title to property:

5) Do you have an opinion about the amount of loss or damage caused by the title problems described in Item 4?

_______ YES ________ NO

a) If yes, what is that amount? $____________. (Please contact us if you need to revise this amount after submitting this form.)

b) How did you determine this amount? (Please attach any documents you have that show how you determined the amount).

6) Have you been sued or threatened with a lawsuit because of the matter described in Item 4?

________ YES ________ NO

a) If yes, how did you learn of the lawsuit or threatened lawsuit?

b) Have you been served with a petition or other legal document in a lawsuit?

_______ YES _________ NO _________ DON'T KNOW

If yes, when and how were you served?

Please attach copies of all documents you have relating to the lawsuit, including letters, the citation, the petition, and the complaint. We may need to ask for additional information about your claim. You are required to provide only the information the policy allows us to ask for.

If two or more persons are named in the policy, both may sign the same form:

_______________________________ _______________________________

SignatureDateSignatureDate

(Not applicable to the Texas Residential Owner Policy)

STATE OF ________________

COUNTY OF ______________

SWORN AND SUBSCRIBED before me, the undersigned authority, this ________ day of __________, 20_____.

___________________________

Notary Public