Premium Deficiency Form

Phone # 972-855-3585
Fax # 877-837-2066
DATE :
NAME OF LENDER :
STREET ADDRESS or PO Box :
CITY : STATE : ZIP :
LENDERS CONTACT :
LENDER PHONE NUMBER :
NAME OF BORROWER/MEMBER :
LOAN NUMBER :
DATE OF REPOSSESSION :
YEAR/MAKE/MODEL OF VEHICLE :
ID NUMBER (LAST 6 DIGITS) :
ATTACH ADDITIONAL REQUIRED DOCUMENTS (or fax to 877-837-2066) :

THESE ARE THE REQUIRED DOCUMENTS :

AFFIDAVIT OF REPOSSESSION

LOAN HISTORY REFLECTING CURRENT BALANCE, CURRENT PAY OFF, OUTSTANDING LATE CHARGES & MONTHLY INSTALLMENTS

COPY OF SECURITY AGREEMENT (NOTE)

  • A.AMOUNT FINANCED, FINANCE CHARGE & TERM OF LOAN MUST BE INDICATED
  • B. IF CREDIT LIFE, ACCIDENT & HEALTH OR MECHANICAL WARRANTY IS INCLUDED ON LEIN; PLEASE PROVIDE REBATE AMOUNT. WE WILL ALSO NEED TO KNOW IF THESE AMOUNTS HAVE ALREADY BEEN DEDUCTED FROM THE CURRENT PAYOFF

COPY OF TITLE
COPY OF CONDITION REPORT
COPY OF PROOF OF SALE

ANY PERSON WHO KNOWINGLY & WITH INTENT TO INJURE, DEFRAUD OR DECIEVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF COMMITTING THE FELONY OF INSURSANCE FRAUD