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CALIFORNIA LICENSED TITLE INSURANCE COMPANIES & UNDERWRITTEN TITLE COMPANIES

ANNUAL VERIFIED REPORTS per California Code of Regulations §2555.2

Company Name

Co. NAIC Code or California UTC Code

Group Name

Group Code

Address

City

State

Zip Code

I declare under penalty of perjury, under the laws of the state of California, that I have examined this report and

the contents thereof, and it is true, correct and complete.

Signature of the Officer

Date

Name of the Officer (Please print)

Phone Number

Fax Number

Title

E-Mail Address

Name of the Contact Person (Please print)

Phone Number

Fax Number

E-Mail Address

This Form Is Due No Later Than: APRIL 29, 20XX

Please submit the completed survey to the Rate Specialist Bureau by sending either:

1)

an electronic copy of the file by e-mail to: rsb@insurance.ca.gov

[ use "CA Title Insurer-April29-Annual Verified Report" as the Subject line]

or

2)

a copy of the file on CD/DVD to the address below.

Any questions / correspondence can be directed to:

CALIFORNIA DEPARTMENT OF INSURANCE

Attn: Rate Specialist Bureau

300 South Spring Street, South Tower, 14th Floor

Los Angeles CA 90013-1230

Tel: (213) 346-6556

Fax: (213) 897-6361

e-mail: rsb@insurance.ca.gov

Certification

CERTIFICATION
I,			,				,
	(Name of Officer -- please print)			(Officer's Title)
declare that I am the chief executive officer of the
					, or the designee of
(Name of Company)
					, the chief excecutive officer,
(Name of Chief Executive Officer or n/a)
and I am authorized to execute this declaration on the chief executive officer's behalf.
I declare under penalty of perjury under the laws of the state of California that I have examined this
report and the information contained herein, and it is true, correct and complete.
	(Signature of the Officer)
Executed at:
			on
	(Place)			(Date)
The signed Certification can be submitted as an electronic file in the Portable Document Format (pdf) or a printed & signed hard copy of the Certification can be mailed to the California Department of Insurance at the address below:
		CALIFORNIA DEPARTMENT OF INSURANCE
		Attn: Rate Specialist Bureau
		300 South Spring Street, South Tower, 14th Floor
		Los Angeles, CA 90013-1230

Instructions

INSTRUCTIONS
for
Annual Verified Reports per California Code of Regulations Section 2555.2
Per CCR §2555.2, all California Licensed Title Insurance Companies (TICs) shall file a report with the Insurance Commissioner on or before April 29th of every calendar year, one for each Underwritten Title Company with whom the Title Insurer had an underwriting agreement in-force during any part of the prior calendar year.
Every Title Insurer shall file an executed and verified report under penalty of perjury under the laws of the state of California by the chief executive officer of the company or his/her designee authorized to execute on behalf of the chief executive officer. The designee shall further verify his/her authorization to execute the verification under penalty of perjury under the laws of the state of California.
Please complete a separate report for EACH Underwritten Title Company which your company had an
underwriting agrement in-force during the report year. Copy & complete the Annual Verified Report page for
each UTC, and save in this workbook.
1.	The full corporate name of the Underwritten Title Company (UTC) with whom the Title Insurer had an underwriting agreement in-force during any part of the prior calendar year.
Answer with one of the following for the named Underwritten Title Company (UTC):
2. (a)	The UTC's March 31st Controlled Business Source report has been reviewed and is substantially correct as it pertains to the title insurer's business with the UTC; or
2. (b)	The information in the UTC's March 31st report has been reviewed and it is insufficient to enable an opinion to be formed as regards to the report's correctness as it pertains to the title insurer's business with the UTC; or
2. (c)	The UTC's March 31st report has been reviewed and is incorrect as it pertains to the title insurer's business with the UTC.
Title Insurers answering (2)(b) - Insufficient Data or (2)(c) - Incorrect Data must also provide the correct information as it pertains to the UTC's business with the title insurer.
If the Title Insurer is not able to provide the correct information, the Title Insurer shall in the April 29th report provide the identity and location of documents, access to data, and names of individuals the Insurance Commissioner may examine with regard to these reports.
Please complete one
This Report Is Due No Later Than: APRIL 29, 20XX
Please submit the completed report to the Rate Specialist Bureau by sending either:
1)	an electronic copy of the file by e-mail to: rsb@insurance.ca.gov
	[ use "CA Title - Controlled Business Source Report - 20xx" for the Subject line]
or
2)	a copy of the file on CD/DVD to the address below.
Any questions / correspondence can be directed to:
		CALIFORNIA DEPARTMENT OF INSURANCE
		Attn: Rate Specialist Bureau
		300 South Spring Street, South Tower, 14th Floor
		Los Angeles CA 90013-1230
		Tel: (213) 346-6556			Fax: (213) 897-6361
		e-mail: rsb@insurance.ca.gov

AnnlVerRpt_UTC

	REPORT YEAR:	ANNUAL VERIFIED REPORTS (CCR Section 2555.2)
		(Report per CCR §2555.2 -- Due APRIL 29, 20XX)
	Name of Company:									NAIC Code:
	Group Name:									Group Code:
	We had an underwriting agreement in-force during all or part of the reporting year with the Underwritten Title
	Company listed below:
1)	Name of Underwritten Title Company:
2)	The UTC's March 31st Annual Report per CCR §2555.2 has been reviewed and is:
				a) Substantially Correct
				b) Insufficient Data
				c) Incorrect Data
	Title Insurers checking either: (b) - Insufficient Data or (c) - Incorrect Data must also provide the correct information as it pertains to the UTC's business with the title insurer.
	If the Title Insurer is not able to provide the correct information, the Title Insurer shall provide the identity and location of documents, access to data, and names of individuals the Insurance Commissioner may examine with regard to these reports. Please use the space below to provide additional information.

Mar31_ContrlldBusiSrc

	REPORT YEAR:	ANNUAL VERIFIED REPORTS (CCR Section 2555.2)
		(Report per CCR §2555.2 -- Due MARCH 31, 20XX)
	Name of Company:					NAIC Code:
	Group Name:					Group Code:
	** Name of UTC:					UTC CA Number:
** If the reporting company is an Underwritten Title Company (UTC), it must simultaneously transmit a copy of this
Report to the Chief Executive Officer (or his/her designee) of each and every Title Insurer with whom the UTC had
an Underwriting Agreement in-force during any part of the reporting year.
		(1)		(2a)		(3b)
	Name of Controlled Business Sources (CBS)			Annual Commission Paid to Controlled Busns Source		Other Consideration Paid to Controlled Busns Source
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL: ALL CONTROLLED BUSINESS SOURCES				0		0

Mar31_CBSrc_byCounty

	REPORT YEAR:	ANNUAL VERIFIED REPORTS (CCR Section 2555.2)
		(Report per CCR §2555.2 -- Due MARCH 31, 20XX)
	Name of Company:	0				NAIC Code:	0
	Group Name:	0				Group Code:	0
	** Name of UTC:	0			UTC CA Number:		0
** If the reporting company is an Underwritten Title Company (UTC), it must simultaneously transmit a copy of this
Report to the Chief Executive Officer (or his/her designee) of each and every Title Insurer with whom the UTC had
an Underwriting Agreement in-force during any part of the reporting year.
		(3)	(4)	(5)	(6)	(6a)	(7)
	Name of County	# of Closed Title Orders that Emanated from Contrld Busns Sources in (1)	Total # of Closed Title Orders in each County	# of Closed Title Orders from Non-Controlled Business Sources	Total Closed Orders - Non-CBS Orders = (4) - (5)	Difference as a Percentage (6)/(4)	% of Closed Orders from Named Cntrlld Bsns Src = (3)/(4)
1	ALAMEDA				0	0.000%	0.000%
2	ALPINE				0	0.000%	0.000%
3	AMADOR				0	0.000%	0.000%
4	BUTTE				0	0.000%	0.000%
5	CALAVERAS				0	0.000%	0.000%
6	COLUSA				0	0.000%	0.000%
7	CONTRA COSTA				0	0.000%	0.000%
8	DEL NORTE				0	0.000%	0.000%
9	EL DORADO				0	0.000%	0.000%
10	FRESNO				0	0.000%	0.000%
11	GLENN				0	0.000%	0.000%
12	HUMBOLDT				0	0.000%	0.000%
13	IMPERIAL				0	0.000%	0.000%
14	INYO				0	0.000%	0.000%
15	KERN				0	0.000%	0.000%
16	KINGS				0	0.000%	0.000%
17	LAKE				0	0.000%	0.000%
18	LASSEN				0	0.000%	0.000%
19	LOS ANGELES				0	0.000%	0.000%
20	MADERA				0	0.000%	0.000%
21	MARIN				0	0.000%	0.000%
22	MARIPOSA				0	0.000%	0.000%
23	MENDOCINO				0	0.000%	0.000%
24	MERCED				0	0.000%	0.000%
25	MODOC				0	0.000%	0.000%
26	MONO				0	0.000%	0.000%
27	MONTEREY				0	0.000%	0.000%
	REPORT YEAR:	ANNUAL VERIFIED REPORT (CCR §2555.2)
	0	(Report per CCR §2555.21 -- Due March 31, 20XX)
	Name of Company:	0				NAIC Code:	0
	Name of UTC:	0			UTC CA Number:		0
		(3)	(4)	(5)	(6)	(6a)	(7)
	Name of County	# of Closed Title Orders that Emanated from Contrld Busns Source in (1)	Total # of Closed Title Orders in each County	# of Closed Title Orders from Non-Controlled Business Sources	Total Closed Orders - Non-CBS Orders = (4) - (5)	Difference as a Percentage (6)/(4)	% of Closed Orders from Named Cntrlld Bsns Src = (3)/(4)
28	NAPA				0	0.000%	0.000%
29	NEVADA				0	0.000%	0.000%
30	ORANGE				0	0.000%	0.000%
31	PLACER				0	0.000%	0.000%
32	PLUMAS				0	0.000%	0.000%
33	RIVERSIDE				0	0.000%	0.000%
34	SACRAMENTO				0	0.000%	0.000%
35	SAN BENITO				0	0.000%	0.000%
36	SAN BERNARDINO				0	0.000%	0.000%
37	SAN DIEGO				0	0.000%	0.000%
38	SAN FRANCISCO				0	0.000%	0.000%
39	SAN JOAQUIN				0	0.000%	0.000%
40	SAN LUIS OBISPO				0	0.000%	0.000%
41	SAN MATEO				0	0.000%	0.000%
42	SANTA BARBARA				0	0.000%	0.000%
43	SANTA CLARA				0	0.000%	0.000%
44	SANTA CRUZ				0	0.000%	0.000%
45	SHASTA				0	0.000%	0.000%
46	SIERRA				0	0.000%	0.000%
47	SISKIYOU				0	0.000%	0.000%
48	SOLANO				0	0.000%	0.000%
49	SONOMA				0	0.000%	0.000%
50	STANISLAUS				0	0.000%	0.000%
51	SUTTER				0	0.000%	0.000%
52	TEHAMA				0	0.000%	0.000%
53	TRINITY				0	0.000%	0.000%
54	TULARE				0	0.000%	0.000%
55	TUOLUMNE				0	0.000%	0.000%
56	VENTURA				0	0.000%	0.000%
57	YOLO				0	0.000%	0.000%
58	YUBA				0	0.000%	0.000%
TOTAL: ALL COUNTIES		0	0	0	0	0.000%	0.000%

Last Revised - June 25, 2008
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