Send Assignment – Select Recovery Agents

Assignment Form

Kindly fill out the Assignment Form with complete information.

Full Name ^*

Company Name ^*

Email ^*

Company Phone Number ^*

Company Address ^*

City ^*

State ^*

Zip Code ^*

Debtor Full Name ^*

Debtor Phone Number ^*

DOB (DD-MM-YYYY)

Debtor SS#

Debtor License

Debtor Address

City

State

DEBTOR Employment Info

Employment Address

Employment City

Employment State

Zip Code

Additional Information

Type of Communication

Money Balance Owed

Enter Monthly Payment

Amount Past Due

Additional Message (If any)

VEHICLE INFORMATION

Vehicle Make

Vehicle Model

Vehicle Color

Vehicle Vin Number ^*

License Plate

Key Code

GPS Tracking Information

Authorization Name Signature ^*

Company Name/Title ^*

Recaptcha

AUTHORIZATION HOLD & HARMLESS

Select Recovery shall fully protect, indemnify and hold harmless and defend Client and each of Client's affiliates, subsidiaries and parents, their respective directors, officers, employees, agents, insurers, attorneys, successors and assigns, for any and all loss, demands, penalties, interest, actions or causes of action whatsoever, including costs, expenses and reasonable attorney’s fees, in any manner arising out of, related to or in connection with, the performance of services by Select Recovery or any subcontractor, assignee or agent of Select Recovery, resulting from: the violation of any federal, state or local law, rule, regulation, or ordinance; or any intentional or negligent act or omission or willful misconduct of or Select Recovery its subcontractors or their officers, agents or employees.

Client (Company) shall fully protect, indemnify and hold harmless and defend Select Recovery and each of its affiliates, subsidiaries and parents, their respective directors, officers, employees, agents, insurers, attorneys, successors, assigns and its approved subcontractors, for any and all loss, demands, penalties, interest, actions or causes of action whatsoever, including costs, expenses and reasonable attorney’s fees, in any manner arising out of, related to or in connection with, or resulting from: the violation of any federal, state or local law, rule, regulation, or ordinance; or any intentional or negligent act or omission or willful misconduct of Client or their officers, agents or employees.

This is your authorization to act as our agents to collect or repossess on sight, the below captioned collateral which is covered by a defaulted contract. You are not to reassign if the vehicle is no longer in your service area. Report your findings and send us a detailed report of your findings with advice.

This indemnification is granted as consideration for your acting as our agent. It is agreed that this contract is executed within your state and that the laws of your state shall be applicable. When there are two states involved, the laws of both states may be applicable. We hereby agree to the conditions of the hold harmless and authorize repossession of the aforementioned collateral.

It is hereby agreed that all fees will be paid in full before vehicle is released unless other arrangements have been approved.