Fillable OWNER CLAIM SUBMITTAL FORM

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OWNER CLAIM SUBMITTAL FORM

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The OWNER CLAIM SUBMITTAL FORM form is 1 page long and contains:

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  • 13 check-boxes
  • 18 other fields

Country of origin: OTHERS
File type: PDF

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(rev. 09/2015)
INSTRUCTIONS: Please fill in all applicable fields below, attach necessary documents if available and submit your request in writing via
one of the following channels:
If you do not receive a response to your request within 5-10 business days after submitting this form or if you have questions regarding
this process please call the National Claims Intake Center at: 888-632-1642 *Signifies required fields
OWNER CLAIM SUBMITTAL FORM
Claimant Information:
Name*
Address*
City State Zip Code
Phone Number*
Property and Policy Information:
Claim Information: (Choose all that apply)
Documents to be attached to all Claim Submissions: (if applicable)
- Copy of Policy and/or Title Commitment from the Insured Transaction (both if available)
- Copy of HUD-1 or Final Settlement Statement from the Insured Transaction
- Recent Title search or Commitment showing the Claims Issue, if obtained by a title company working on a recent transaction
- Any correspondence or notices received from an adverse party
- Pleadings served on the insured claimant, if the claim involves litigation
- Survey if one is available on claims involving issues of Access, Easement, Legal Description or Survey / Boundary / Encroachment
- Tax bills or notices if claim issue involves Taxes / Assessments
- Any other relevant documents obtained by the owner or counsel representing the owner
Fax Number
Represented by (if applicable)
Property Owner(s)
Insured Property Address
Policy Number
Zip CodeCountyCity
Contact E-mail
Today's Date
Prior Lien Defense / Lawsuit / Bankruptcy Legal Description Property Line Dispute / Survey Issues
Date
Access / Easement / Encroachment
Unpaid Taxes / Special Assessments Mobile Home Affixture Escrow / Settlement Fraud / Forgery
Vesting / Interests Missing Authority / Defective Notary Unrecorded Documents Other
Mail: First American Title Insurance Company
Attn: National Claims Intake Center
5 First American Way, Santa Ana, CA 92707
Brief explanation of claim* (If additional space is needed for explanation attach as a separate document):
State*
Fax:
877-804-7606
Email:
claims.nic@firstam.com
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OWNER CLAIM SUBMITTAL FORM

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Completed 29 March 2021

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