INSURED BY: Prime Insurance, Inc.
Automobile Recovery Services, Inc.
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Submit an Assignment

If you have any questions about submitting an assignment form, please call us Toll Free at 1.800.422.7376. Otherwise, submit the information via this web page or print out this page, fill out the information and fax it to us at 1.513.471.3535.

* Required Fields
Email: *
Legal Owner:
Owner's Address:
Assigned By: *
Phone: *
Fax:
Date:
Extension:
Watts or 800 #:
 Debtor Information:
Debtors Name:
Home Address:
City:
State: Zip:
Employer:
Work Address:
Home Phone:
DOB:
Spouse's Name:
Spouse's DOB:
Work Phone:
SS #:
Spouse's SS #:
 Collateral Property Information:
Year:
Model:
License #:
Ignition Key #:
VIN #:
Make:
Color:
State:
Trunk Key #:
 Loan Information:
Loan Number:
Past Due Date:
Past Due Amount:
Assignment Type:
Balance:
Monthly Payment:
The issue of this assignment requires a price quote in advance:
Yes No

Special Instructions:


Storage Instructions:

This is authorization to act as our agent to collect or reposses the above collateral. We agree to indemnify, and hold harmless from and against any and all claims, damages, losses, and actions including reasonable attorney fees, resulting from and arising out of your efforts to collect and or reposses claims, except, however, as such may be caused by or arise out of negligence or unauthorized acts on the part of you, your company, its officers, employees or its agents.

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