Submit an Assignment

Safety Adjusters, Inc.
Services Available throughout Southeastern Texas.
We cover much of Texas and have Affiliates Nationwide. Check Safety Adjuster's Coverage Area For Details.


Corporate Headquarters
P.O. Box 2704
Beaumont, Texas 77704-2704
Nationwide Assignment Center
Phone : 1.409.833.8380
Fax : 1.409.833.6124

Lienholder:

Address:

City: State: Zip:

Phone: Extension: Fax:

E-mail:

Collector:

Debtor:

Address:

City: State: Zip:

Phone: Extension: Fax:

E-mail:

Social Security Number and Date of Birth:

Employment:

Address:

City: State: Zip:

Phone: Extension: Fax:

Collateral Year, Make & Model:

Plate, State & Color:

Key Numbers:

Vehicle Identification Number:

Loan #:

Past Due Date:

Monthly Payment: Loan Balance:

Assignment Type:

Note: Should you have any information regarding family members, relatives of the debtor, or any unique or defining information that would be helpful in the recovery of your vehicle, please enter that information in the Instructions space below.

This is your authorization to act as our agent to collect or repossess the above collateral. We agree to indemnify and hold you 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 repossess 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.

Authorized by:Date:

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Any questions? Please contact us at 1.409.833.8380. You may also print this form and Fax it to us at: 1.409.833.6124

You may also contact us via email at:

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