Your Name:
Company Name:
Your Email:
Your/Company Website:
Your Address: (City, State, Zip)
Your Telephone Numbers:
Work:
Home:
Fax:
Cell:
Type of Debt: Consumer Business
Your business Type: (Choose one)
Medical Dental Property Management Commercial/Retail
Bank Credit Union Individual Judgment Creditor
Other (Describe)
Has the debt been reduced to a Judgment? Yes No
Amount of the Debt:
Date of last service, breach, payment (whichever is latest):
Has this account previously been assigned to another collection agency or attorney for collection? Yes No
FUTURE WORK
Estimate of Future Assignment Workload:
This one only 1-10 per month 11-25 per month >25 per month
Average Age of Accounts to be Assigned:
< 1 year 1-2 years 3-4 years
Does your documentation generally include (Check all that apply):
Full name of Debtor Full address Home Telephone Work Telephone Cell Telephone Emergency Contact Telephone
Social Security Number Driver's License Date of Birth Bill history Your in-house collection notes
COMMENTS:
If you have any additional information or questions, please type them below.
We will generally respond to you within 3 business days with a fee quote based on the information submitted.