Submit Assignment

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Authorization and Hold Harmless

* InvoluntaryVoluntaryField Visit

 

BORROWER INFO


BUYER:

 
First Name:     Last Name:
Street:    Apt/Suite:
City:    State:    Zip:
Home Phone:    Cell Phone:
   
Employment:    Phone:
POE Address:
POE City:    State:   Zip 


CO-BUYER:

 
First Name:     Last Name:
Street:    Apt/Suite:
City:    State:    Zip:
Home Phone:    Cell Phone:
   
Employment:    Phone:
POE Address:
POE City:    State:   Zip 

 

COLLATERAL INFO


*Year:    * Make:     *Model:
Color:    License Plate:    State:
*VIN:

Please note that if the unit is a 4x4 (Four Wheel Drive) or an AWD (All Wheel Drive) we request a
pre-approved $125.00 flat bed fee as traditional tow methods would damage the unit. This fee is
applied to the final repossession costs.

If the unit is one of these please check the following box. Thank you.
(Unit is 4x4 or AWD)

 

ACCOUNT INFO


*Account Number:            Days Past Due:
Unpaid Balance:        Amount Past Due:
Payment Amount:       Next Payment Due:
Additional Info:
 
PDF's, JPEG, or GIF  
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Document 4
   

CLIENT INFORMATION & AGREEMENT


*Company Name:
*Your Email:
*Contact Name:    *Phone:    Ext:
*Billing Address:

* This is your, Premier Finance Adjuster's, authorization to act as our agent to collect and/or repossess on sight, the above collateral which is covered by contract. Report any findings and send detailed condition report with invoice. We agree to indemnify you harmless from and against any and all claims including court costs, reasonable attorney fees, and other expense of litigation, except for unauthorized acts by Premier Finance Adjusters. This indemnification is granted as considered for your acting as our agent. It is agreed that this contract is executed within your coverage area and that the laws of each state shall be applicable. When there are two states, acknowledge and keep us fully informed.

* AGREED IN FULL