Spilt Loan Purchase

This application is for placing a title insurance order for a residential Split Loan Policy, a.k.a. Bifurcated Loan Policy. Lending institutions can now choose the title company they want for insuring them on residential purchase transactions and for conducting the loan closing. Please call our office at (920) 235-0017 for the cost of our closing fee. (Note: Assurance Title honors the same closing fee rate that is quoted to their lender customers on standard purchase closings). The Owner's Policy, in this situation, would be issued by a different title company authorized to issue title insurance in Wisconsin.

If you would prefer to download the PDF verison of this form you can do so here: 

Title Rate

The title rate for the Residential Bifurcated Loan Policy is $250.00 up to the sale price of the property. If the loan amount would exceed the sale price, the rate per thousand for that rate category would apply. Refer to Title Insurance Rate Schedule on our website for the current Wisconsin title insurance rates. A sixty year search is required on all Bifurcated Loan Policies, unless Assurance Title is supplied with a copy of the existing Owner's or Loan Policy in effect. (Note: Title evidence can be uploaded using the application form below.)


Application for Title Insurance:
Residential Split (Bifurcated) Loan Policy

Directions:  To ensure accuracy, please complete all asterisk items below and as many of the non-asterisk items to assist us in completing the title order process.

All supplied information will be kept strictly confidential.
Assurance Title complies with the ALTA Best Practice Policies. View our "Privacy Policy Notice."

Applicant Information

Name of Person Placing Order:(*)
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Lending Institution:(*)
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Email:(*)
Please enter a valid email address.
Billing Address:(*)
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Billing Address 2
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Billing City:(*)
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Billing State:(*)
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Billing Zip(*)
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Phone(*)
Please enter a valid phone number (xxx-xxx-xxxx)
Date Needed By:(*)
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Fax:
Please enter a valid fax number (xxx-xxx-xxxx)

Residential Bifurcated Loan Policy Information

Loan Reference Number:
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Loan Amount:(*)
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Loan Type:(*)
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Current Property Owner Name(s):(*)
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Property Address:(*)
Please enter a property address.
Proposed Insured:(*)
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Anticipated Closing Date(*)
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How many parcel(s) does the subject property contain?(*)
Please enter only numbers.
Requested Endorsements:
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Special Instructions:
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To receive discounted Re-Issue Rate, please upload existing Owner's or Loan policy.

If you cannot upload, please email a PDF of the policy to us at This email address is being protected from spambots. You need JavaScript enabled to view it.. If scanned images are not possible, please fax the title policy to (920) 235-2122 or drop it off at our office.
Prior Title Evidence:(*)
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A sixty year search is required on all commercial loan policies if Assurance Title is not supplied a copy of existing title evidence.
Upload File:
File types accepted: PDF, JGP, or JPEG under 500KB
File types accepted: PDF, JGP, or JPEG under 500KB

Important: Upon completion of the above order form you will receive an email confirmation that we have received your title order request. If you do not receive the confirmation, please contact us at (920) 235-0017.
Submit this Application:

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We have endorsed and adhere to the "Title Insurance and Settlement Company Best Practices Policies".