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:

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 above 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

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