T-00 TX Verification of Services Rendered
VERIFICATION OF SERVICES RENDERED – Form T-00INSTRUCTIONS 1. The Agent/Entity desiring to be paid shall complete Section 1, sign, date and deliver the form, together with a written itemized statement or invoice, when the work is performed or delivered.2. The Agent/Underwriter issuing the policy shall complete Section 2.3. The Agent/Underwriter paying for the work shall complete Section 3, sign, date and deliver a copy of the form to both the Agent/Entity being paid and the Agent/Underwriter issuing the policy.4. All parties shall retain in their records a fully signed copy of this Form T-00 and a copy of the written itemized statement or invoice.
SECTION 1 – INFORMATION FROM AGENT/ENTITY REQUESTING PAYMENT1. Service for which payment is requested: o Furnishing Title Evidenceo Title Examinationo Closing the Transaction Address of location where work was done for selected service(s): ________________________________________________________________ Order/File/GF# assigned to this order by Agent/Entity doing the work: ________________________________________________________________ 2. AGREEMENT REGARDING PAYMENT FOR SERVICE: Percentage or amount of premium (remaining after remittance to Underwriter) agreed to be paid to the Agent/Entity doing the work:____________________% or $_________________________ 3. INFORMATION ABOUT AGENT/ENTITY DOING THE WORK:Type of entity:o Texas Underwriter o Texas Title Agent o Texas Attorney at Law or Texas PC organized to provide legal servicesName: _______________________________________________Address: _______________________________________________City, State/ZIP _______________________________________________Texas Department of Insurance Number or Texas State Bar #: _____________ Undersigned certifies that the service for which payment is requested was actually performed. __________________________________ Date: _____________Signature of Authorized Representative for Agent/Entity Doing the Work
SECTION 2 – INFORMATION FROM AGENT/UNDERWRITER ISSUING THE POLICY4. Date of Policy (ies): ________________ County Code(s): __________________ Order/File/GF# assigned to this Policy (ies) by Issuing Agent/Underwriter: ___________________ 5. Issue Type: o Out-of-County (2) – Title Evidence from Texas Agento Multi-County (1) – Title Evidence from Texas Agento Best Evidence (0) – No title evidence from Texas Agent 6. Liability and Premium Amount(s):Owner Title Policy (ies) Liability: $____________ Premium: ____________Mortgagee Policy (ies) Liability: $____________ Premium: $ ___________Endorsement(s) $______________Other $______________ TOTAL $______________ Final amount remaining after remittance to the Underwriter: $_____________Final amount paid to the Agent/Entity doing the work: $_____________ 7. INFORMATION ABOUT AGENT/UNDERWRITER ISSUING POLICY:Name: ________________________________________________Address: ________________________________________________City, State/ZIP ________________________________________________Texas Department of Insurance Number: _______________________________
SECTION 3 – INFORMATION FROM AGENT/UNDERWRITER PAYING FOR THE WORK8. INFORMATION ABOUT AGENT/UNDERWRITER PAYING FOR THE WORK:Name: ________________________________________________Address: ________________________________________________City, State/ZIP ________________________________________________Texas Department of Insurance Number: _______________________________ Order/File/GF# assigned to this order by Agent/Underwriter paying for the work: __________________Undersigned certifies that the above description of work performed is accurate and the final amount shown paid is correct. ________________________________ Date: ________________Signature of Authorized Representative for Agent/Underwriter Paying for the Work
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