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Blanket Single Interest Claim


Please complete the form in full providing all necessary information. Thank you.

USE THE TAB KEY TO MOVE BETWEEN FIELDS

Claim Information Details:

Today's Date:

Your Name:

Your Financial Institution:

Your telephone number including area code:

Your Email Address:

Borrower Name(s):

Borrower Street Address:

Borrower City:

State:

Zip Code:

Borrower's Loan Number:

Year of Vehicle:

Make of Vehicle:

Vehicle Model:

Vehicle Color:

Vehicle VIN Number:

Type of Loss (put YES in appropriate box):

REPOSSESSED VEHICLE COVERAGE CLAIM – NO DAMAGE
REPOSSESSED COLLATERAL CLAIM WITH DAMAGE
CONVERSION, EMBEZZLEMENT AND SECRETION (SKIP CLAIM) If Applicable
INSTRUMENT NON-FILING CLAIMS - If Applicable

Date of Loss:

Loan Balance:

Payoff:

Please enter details of loss (be specific):

Please enter areas of damage (be specific)
(DOES NOT APPLY TO CONVERSION, EMBEZZLEMENT & SECRETION OR INSTRUMENT NON-FILING CLAIMS):

PRESENT LOCATION of Collateral (Name, Address, City, State and Zip):

PRIMARY INSURANCE - at the time of loan:

Insurance Company:

Policy #:

Insurance Agent:

Address:

Telephone Including Area Code:

Date of Coverage:

Before submitting this form, please take a moment to review the information you've provided for accuracy.

       


Evans, Simpson & Associates, Inc.
PO Box 1549 - Snellville, GA 30078
800-676-1609
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