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:    Ext:
Fax: 
E-mail:
Collector: 
Debtor:
Address: 
City:
 State:     Zip:
Phone:
Fax:
E-mail:
SSN and Date of Birth:
Debtor's POE:
Address: 
City:
State:    Zip:
Phone:    Ext:
Co-Maker:
Address: 
City:
 State:     Zip:
Phone:
Fax:
E-mail:
SSN and Date of Birth:
Co-Maker's POE:
Address: 
City:
State:    Zip:
Phone:    Ext:
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 aiding us in the recovery of your vehicle, please enter that information in the "Instructions" space below.

Authorized by:
Date:
*All fields marked with an asterisk are required

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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