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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