Claim Placement Form

Please complete the following form.

Creditor:

Company - required
Name
Address
City
 State
 ZIP
Phone
 Fax
E-mail

Please process claim for:

Immediate Collection 10 Day Free Demand
20 Day Free Demand
30 Day Free Demand

Debtor Information:

Debtor - required
Contact Name
Title
Address
City
 State
 ZIP
Phone
 Fax
E-mail
Debtor Principal Officer
Amount
$
Add Interest
$
Total Amount Due - Required
$
Date of Original Invoice
Date of Last Payment

Remarks


Have you ever placed a claim with us in the past?
Yes No

 
PLEASE REPORT ALL PAYMENT AND COMMUNICATIONS PROMPTLY.   LEGAL ACTION SHALL NOT BE INSTITUTED WITHOUT APPROVAL AND AUTHORIZATION.   WITHDRAWAL OF CLAIMS WILL BE SUBJECT TO OUR STANDARD FEES.   See Fee Schedule for further details.

Please send us a current statement of account and credit application to assist us in maximizing the dollars recovered.