| *Private
Seller/Insurance/Company/Other |
*Claim
or Debtors account #: |
_______________________________________
_______________________________________
_______________________________________ |
_______________________ |
| *Seller
Contact/Adjuster |
Phone:
___________________ |
| _______________________________________ |
Fax:
_____________________ |
|
E-mail:
___________________ |
| (circle
one) Boat / Motor Home / Camper /
Motorcycle / Engine / Car / Other |
| *Year:________
*Length:__________
*Make:______________
Model:______________ |
| *HIN
or VIN:_____________________________ |
Trailer:
_______________________________ |
|
Trailer
VIN: ____________________________ |
| Surveyor:_______________________________ |
Phone:________________________________________ |
| Address:
______________________________ |
Fax:__________________________________________ |
|
______________________________ |
|
| *Title
Holder/Former Owner: |
Phone:________________________________________ |
| ______________________________________ |
Fax:
__________________________________________ |
|
*Circle all that apply: Document
/ Title / Registration |
| *Location
of Title, Type of Title-State, Liens: |
| ___________________________________________________________________________________________________ |
| Cause
of Damage or Other Reason for Selling: |
| _____________________________________________________________________________ |
| Special
Instructions:
_______________________________________________________________ |
| _____________________________________________________________________________ |
| *Location
of Asset: |
*Phone:_____________________ |
| _____________________________________ |
Fax:
_______________________ |
| _____________________________________ |
Email:
______________________ |
| Storage
Charges Due:$___________ |
Daily
Storage Charges:$_______________ |
| *Insured
Value: $________________ |
Monthly
Storage Charges:$____________ |
|
|
| It
is understood that a commission plus special expenditures will
be deducted from proceeds and itemized with complete summary. |
| |
| Limitation
of Liability. Certified Sales, Inc. maximum liability for
the breach of any obligation in connection with this Agreement
or the Sales, and any and all damages of any type or nature (whether
in contract, tort or otherwise) sustained or claimed by the Buyer
or any other person or entity in connection with this Agreement
or the Sales, shall be limited to the amounts actually received
by Certified Sales, Inc. as compensation from the Seller. |
_________________________________
Signature
Title |
|
____________________
Date |
| |
| *
Please make sure to provide required fields
information. |