Eagle Adjusters, Inc.

Corporate Headquarters
2834 Hamner Ave #132 
Norco, CA. 92860

Phone: 909.673.1005 | Fax: 909.923.3002

Lienholder: 

Address: ......

City:.............State:Zip:..

Phone: .........Ext: .. Fax: 

E-mail:..........

Collector: .....

Debtor:.. 

Address:..

City: .........State:Zip:.

Phone: ......Ext:..Fax: 

E-mail:.......

SS#/DOB: 

Employment:

Address: ........

City: ..............State:Zip:..

Phone:............Ext.:..Fax: 

Collateral Yr, Make, Model:

Plate, State & Color: ...............

Key Numbers:............... .........

Vehicle Identification Number:.[Be sure to include all 17 numbers]

Loan Number: ..

Past Due Date: .. .

Monthly Payment: Loan Balance: 

Assignment Type:  Involuntary Voluntary  Contact and Collect  Condition Report DMV  MVR 

Note: Should you have any information regarding family members, relatives of the debtor, or any unique or defining information that would be helpful in aiding us 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.

Any questions? Please contact us at 909.673.1005
Or you may also contact us via E-mail at: