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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: MARCH 31, 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-March31-Controlled Business Source 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 Section 2555.2, all California Licensed Underwritten Title Companies (UTCs) and Title Insurance Companies (TICs) shall file a report with the Insurance Commissioner on or before March 31st of every calendar year, to report information on Controlled Business Sources for the preceding twelve months ending December 31.
Every Title Insurer and Underwritten Title Company 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.
Underwritten Title Companies must also simultaneously transmit a copy of this report to the chief executive officer, or the chief executive officer's designee, of each and every Title Insurer with whom the UTC had an underwriting agreement in-force during any part of the prior calendar year.
For the Report Year, please provide:
Item:	Description
(1)	The Complete Name of each Controlled Business Source (CBS).
(2a)	Annual Commission Paid to each Controlled Business Source named in (1).
(2b)	Annual Other Consideration Paid to each Controlled Business Source named in (1).
The Following Data is for Each County business was written in:
Column 3:	Number of closed title orders that emanated from each named Controlled Business Source.
Column 4:	Total number of closed title orders.
Column 5:	Total number of closed title orders from Non-Controlled Business Sources.
Column 6:	Calculated: Col. 4 - Col. 5
	Total Closed Title Orders from All Controlled Business Sources
		= (Total # of Closed Orders - Total # of Closed Orders from Non-CBSs)
Column 6a:	Calculated: Percentage of Difference = Col. 6 / Col. 4
Column 7:	Calculated: Percentage of Closed Title Orders from Controlled Business
		Source named in (1) = Col. 3 / Col. 4
This Form Is Due No Later Than: MARCH 31, 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

ControlledBusiSource

	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

CntrldBusiSource_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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