BLANKET SINGLE INTEREST CLAIM

https://www.evans-simpson.com/blanket-single-interest-claim.html

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

Claim Information Details:

Today's Date:

Your Name

Your Financial Institution

What is 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:

REQUIRED INFORMATION BY CLAIM TYPE:

REPOSSESSED VEHICLE COVERAGE CLAIM – NO DAMAGE:

Claim Form

Copy of Security Agreement
Copy of Title

Copy of Payment History (entire history) indicating current balance and next due date

Copy of repossession affidavit

REPOSSESSED COLLATERAL CLAIM WITH DAMAGE:

Claim Form

Copy of Security Agreement
Copy of Title

Copy of Payment History (entire history) indicating current balance and next due date

Copy of repossession affidavit

CONVERSION, EMBEZZLEMENT AND SECRETION (SKIP CLAIM):

Claim Form

Copy of Security Agreement
Copy of Title

Copy of Payment History (entire history) indicating current balance and next due date

Copy of Credit Application
Copy of Fully Completed Hold Harmless Form
Copy of Collection Department Notes
Current Credit Report
Skip Tracer/Repot Agent Notes
Copy of Bill of Sale or Auto Dealer's Worksheet

Copy of Driver’s License

INSTRUMENT NON-FILING CLAIMS

Claim Form

Copy of Security Agreement
Copy of Title

Copy of Payment History (entire history) indicating current balance and next due date

Copy of collection notes

Proof of superior lien

Location of collateral MUST be provided

Once you have submitted these claim details online:

Submit the following applicable information as an Adobe Acrobat PDF file via email to:

claims@evans-simpson.com

OR

Mail to:

Evans, Simpson & Associates, Inc.
PO Box 1549

Snellville, GA 30078-1549

Email: claims@evans-simpson.com
Phone: 770-979-1354

Fax: 770-979-3173

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