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Interstate Adjusters S.A., Inc.
Assign by Fax


Please Read:
To assign by Fax, fill out this form, then click the "NEXT!" button at the bottom of the page to display your completed faxable form.

Interstate Adjusters S.A., Inc.
San Antonio, TX 78265
Fax 210.646.8677

Your Email Address (Required)

Legal Owner Information

Legal Owner
Owner's Address
Assigned By Date
Phone Extension
Fax Watts/800 #

Debtor Information

Debtors Name
Home Address
Work Address
Home Phone Work Phone
Spouse's Name
Spouse's DOB Spouse's SS #

Collateral Property Information

Year Make
Model Color
License # State
Ignition Key # Trunk Key #

Loan Information

Loan Number Balance
Past Due Date Monthly Payment
Past Due Amount
Assignment Type

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.

Press the "Next!" button to complete your Faxable form:

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