Lost or Defective Title Bond Application Form
SSL Please complete and submit the following form with confidence: Hill & Usher does not sell or otherwise transfer any of its database information to other entities for the purposes of marketing to you.

 

If the Bond Is for a Business
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Business Telephone

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(hold the CTRL key to select multiple entities)

 

Person Signing the Bond
Name Exactly as it is to Appear on the Bond (the person applying for title or registration will be required to sign the bond)
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Home Telephone

( )
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Daytime Telephone

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Mobile Telephone

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Download Personal Financial Status Form

 

The Bond
Month Day Year
Airplane

All-terrain Vehicle (ATV)

Boat

Personal Watercraft (jet skis - PWC's)

Bus (12+ seating)

Car (passenger)

Crossover (CUV - car with SUV features)

Kit

Manufactured/Factory-built/Modular Home

Motor Home (recreation vehicle)

Motorcycle/Scooter

Snowmobile

Sport Utility Vehicle (SUV)

Other Utility Vehicle (farm/construction vehicle)

Travel Trailer/5th Wheel

Camping Trailer

Other Trailer

Pickup Truck

Truck

Truck Camper

Van

Van Conversion

Other

Types of Boats

 

Additional Information

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By submitting this request, you attest to the accuracy and completeness of the information provided. You understand that no coverage is in force until a policy of insurance is approved and issued on your behalf. Hill & Usher will not be held responsible for coverages not available, coverages not requested by you, or limits not sufficient at the time of this submission.

No application will be submitted or bound with the insurance carrier until you have accepted our quotation.

IMPORTANT INFORMATION REGARDING THE USE OF YOUR INSURANCE/CREDIT SCORE:
By submitting this request for a quotation, you hereby permit the agency, its employees, owners, and affiliated insurers (HILL & USHER, LLC) to use data contained within your "insurance credit score" as the basis for determining your eligibility for our products where permitted by law.  You understand that an unacceptable "insurance credit score" as deemed by our insurance carrier(s) may result in your ineligibility for coverage.  You agree to hold HILL & USHER, LLC harmless from fault or liability in the event that your "insurance score" is unacceptable to the carrier(s), even if the information contained therein proves inaccurate in any way.
Due to privacy concerns and the proprietary nature of "insurance scores," HILL & USHER, LLC will not know the details of your "insurance score." In compliance with the Fair Credit Reporting Act http://www.ftc.gov/os/statutes/fcra.htm, you have the right to request information about your "insurance score" or to dispute in writing the results of an unfavorable "insurance score."  Upon request, HILL & USHER, LLC will furnish you with contact information for the relevant credit rating bureau.  Your "insurance credit score" is a combination of your business or personal credit history, loss history, and other factors that may reasonably predict the likelihood of future claims.

If you have Questions/Problems with this form please email the webmaster or call our office at (602) 956-4220 between 8AM and 5PM Monday through Friday, Arizona time.
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Agency Principal
Hill & Usher
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Phone: (602) 956-4220 | Fax: (602) 956-4418