Submit a Claim

To place an account with our firm, please fill out the below form and attached supporting documents in pdf format.

Debtor Information:

Your Name (required)

Amount owed (required)

Address (required)

City/State/Zip Code

Your Email (not required)


Contingency %

Initials (sales person)

Date of Recent Unpaid Invoice

Account and/or Invoice #

Additional Amounts

Name of Individual or Company Responsible (required field)




Please provide any of the following information (if applicable); invoices, contracts, bills of lading, insufficient checks, proof of delivery, guarantee, and/or credit applications.

Client Information:

Name (required field)


Phone (required field)

Authorized By

Email (not required)

File Upload (not required)