"*" indicates required fields

Client Information

Address*

Collateral Information

Borrower Information

Borrower Name*
Address*
Borrower's Work Address

Instructions

Instructions*

If Repossessed

Balance Information

Last Payment Date*
If collateral is repossessed, tell us where you would like it taken to. If no destination is specified, it will be taken to our secure storage.

Documentation

Please attach a copy of the title or lien card, security agreement, 10-day demand letter, credit application, collection notes, and any other notes pertaining to this file.
Drop files here or
Accepted file types: doc, docx, pdf, jpg, png, jpeg, Max. file size: 5 MB, Max. files: 4.

    Hold Harmless Agreement

    CLIENT agrees to defend, indemnify and hold Service Provider harmless from any and all claims, demands, damages, liability, causes of action, actions, judgments, awards, fines, penalties, costs, expenses of any kind and nature whatsoever, contingent or liquidated (including attorney’s fees), arising from or relating to CLIENTS acts or omissions in connection with referring Assignments to Service Provider, including but not limited to referring an assignment where CLIENT’S client did not hold a present right to repossess the collateral, excepting only such claims as are the result of the sole negligence or misconduct of Service Provider.  CLIENT’S obligations under this Agreement shall include the duty to defend and/or pay for the defense of Service Provider in any action or other legal proceeding with legal counsel that is acceptable to Service Provider in its sole and complete discretion.
    Name*
    Clear Signature
    This field is for validation purposes and should be left unchanged.