Agent Onboarding

Please select one of the following Options below

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Company

This field is for validation purposes and should be left unchanged.

Email*

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Email*

Who is this form for?*

Individual

Entity

This form must be completed by each Owner, Partner, Attorney, Officer, Director, and/or Manager.

Must be completed by Corporate Officer, General Partner or Managing Partner.

Full Legal Name of Agency*

Agency’s DBA, if any*

Physical Address*

Mailing Address*

Same as Physical Address

Not the same as Physical Address

Mailing Address*

Main Phone Number*

Federal Tax ID*

Website*

State(s) in which Agency is licensed and will be issuing title insurance*

Services Provided*

List Other Here*

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Prior address(es) of Agency for the previous 10 years*

Address

From Date

To Date

Owners or partners owning 10% or more of Agency*

Complete Name

Home Address

Job Title

% Ownership Interest

Please list all current and past title insurance underwriters represented*

Names

Has Agency or any of its principals, officers/employees ever been the subject of any disciplinary action by any industry, state or federal regulators or State Bar?*

Yes

Please Explain*

Have any of your principals, officers or employees ever been convicted of any criminal activity?*

Yes

Please Explain*

Individual Name*

Position with Agency*

Cell Phone Number*

Prior residence address(es) of Individual for the previous 10 years*

Address

From Date

To Date

Drivers Licence Number*

State*

Date of Birth*

Social Security Number*

Have you ever been turned down for a fidelity bond?*

Yes

Please Explain*

Is there or will there be a business relationship between Agency and Individual’s Spouse?*

Yes

Please Explain*

Education: Please list each College, University or Post Graduate School attended*

Name Of School

City,State

From Date

To Date

Degree

Date Graduated

Employment history of Individual for the previous 10 years (most recent employment first)*

From Date

To Date

Employer Name

Address

Supervisor

Job Title

By submitting this application, I certify that I have the authority to represent that the information provided or statements made in this application or on any attachment(s) are true and correct. I understand that the information and/or statements shall be used to determine my firm or agency’s eligibility and my personal eligibility for appointment as an Issuing Agency of American Security Title Insurance Company I understand that any misleading or false information furnished or pertinent information omitted by myself shall constitute grounds for immediate termination of any agreement entered into between myself and/or the Agency and American Security Title Insurance Company.

By submitting this application, I certify that I have the authority to represent that the information provided or statements made in this application or on any attachment(s) are true and correct. I understand that the information and/or statements shall be used to determine my firm or Agency’s eligibility for appointment as an Issuing Agency of American Security Title Insurance Company. I understand that any misleading or false information furnished or pertinent information omitted shall constitute grounds for immediate termination of any agreement entered into between the Agency and American Security Title Insurance Company.

Applicant Signature*

Today's Date*

Applicant Name*

Title*

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Corporate Office

American Security Title Insurance
1000 W 15th Street
Edmond, OK 73013

Operating Hours

Monday - Friday, 8 am - 5 pm

Phone

(405) 348-1248

Your Privacy

We are committed to protecting your privacy. Your information will be used in accordance with the applicable data privacy law, our internal policies, and our privacy policy.

We will handle your information with care and respect for your privacy.

Need More Information?

Please contact American Security Title Insurance Company for inquiries. Our team is committed to providing prompt, comprehensive assistance, ensuring you have all the necessary information for your decisions.

Application for Appointment as a Title Insurance Policy Issuing Agency

Need More Information?