NJ Consent to Special Rate or Charge 6-03

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(name of underwriter or agent)

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(address of underwriter or agent)

Application No. _____________

CONSENT TO SPECIAL RATE OR CHARGE

The undersigned are the applicants for an examination of title or title insurance under the above application number. Because the examination requires extraordinary time or expertise, or because the insurance involves special risks or unusual hazards, we have been advised that a special charge estimated to be $ __________ will be made in connection with the following services or coverages:

We have been advised both of our rights to withdraw the title insurance application or order and of our right to appeal the imposition of this special charge to the Commissioner of Insurance. We request that the examination be undertaken or the insurance written, and we consent to pay the special charge.

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No guidelines are available for this form at this time.