Quick Placement Form

Complete the claim placement form below to begin the recovery process. Your information is kept strictly confidential. This form requires an email account. Otherwise you may print the form and fax it to us at 719-380-8613.

Fields in red marked with an asterisk (*) are required.

Let's Get Started!

DEBTOR #1

Debtor #1 Name:*

Debtor #1 Address:*

Debtor #1 City:*

Debtor #1 State*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonDistrict of ColumbiaWest VirginiaWisconsinWyoming

Debtor #1 Zip Code*

Debtor #1 Phone:*

(no dashes - ex: 8885551414)

Amount:*

Invoice Date:*12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Type of Business:

Individual Responsible:

TELL US ABOUT YOUR DEBTOR

Last Time You Received a Payment?

Are They Avoiding You?

 Yes

 No

Your Response:

Any Broken Promises?

 Yes

 No

Your Response:

Problems with NSF Checks?

 Yes

 No

Your Response:

Is there anything else you would like us to know about this account?

DEBTOR #2

Debtor #2 Name:

Debtor #2 Address:

Debtor #2 City:

Debtor #2 State:Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonDistrict of ColumbiaWest VirginiaWisconsinWyoming

Debtor #2 Zip Code:

Debtor #2 Phone:

(no dashes - ex: 8885551414)

Debtor #2 Amount:

Debtor #2 Invoice #:

Debtor #2 Invoice Date:12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Debtor #2 Type of Business:

Individual Responsible:

TELL US ABOUT YOUR DEBTOR:

Last Time You Received a Payment?

Your Response:

Are They Avoiding You?

 Yes

 No

Your Response:

Any Broken Promises?

 Yes

 No

Your Response

Problems with NSF Checks?

 Yes

 No

Your Response:

Is there anything else you would like us to know about this account?

DEBTOR #3

Debtor #3 Name:

Debtor #3 Address:

Debtor #3 City:

Debtor #3 State:Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonDistrict of ColumbiaWest VirginiaWisconsinWyoming

Debtor #3 Zip Code:

Debtor #3 Phone:

(no dashes - ex: 8885551414)

Debtor #3 Amount:

Debtor #3 Invoice Date:12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Debtor #3 Invoice #:

Debtor #3 Type of Business:

Debtor #3 Individual Responsible:

TELL US ABOUT YOUR DEBTOR

Last Time You Received a Payment?

Your Response:

Are They Avoiding You?

 Yes

 No

Your Response:

Any Broken Promises?

 Yes

 No

Your Response

Problems with NSF Checks?

 Yes

 No

Your Response:

Is there anything else you would like us to know about this account?

CLIENT INFORMATION:

SIC Code:

Status:*

 New Client

 Existing Client

Company Name:*

Phone:*

(no dashes - ex: 8885551414)

Fax:*

(no dashes - ex: 8885551414)

Email:*

Address:*

City:*

State:*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonDistrict of ColumbiaWest VirginiaWisconsinWyoming

Zip Code:*

Authorized by:*

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