Split 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 the current Simultaneous Loan Policy fee according to Wisconsin filed rates 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.

Please contact our office if you have any questions on determining the Residential Split (Bifurcated) Loan Policy fee.

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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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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Please enter a valid phone number (xxx-xxx-xxxx)
Date Needed By:(*)
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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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Submit this Application:

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