Fields marked with an * are required

Assignee Information

Primary Debtor Information

Secondary Debtor Information

Collateral Information

Prior Repossession

Authorization and Hold Harmless Agreement

In submitting this assignment we agree to indemnify, hold harmless, and defend Source One Adjusters of Ohio, Inc. from and against any and all claims, damages, losses, actions, awards, fines, costs, and expenses which arise out of our negligent acts or willful misconduct or our violation of any federal, state or local law, rule, regulation or ordinance in making and managing this assignment.

I am duly authorized by my company to make such an assignment. By typing my name in the box below and pressing the submit button below I am digitally signing this authorization.