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online placement form

Have an account(s) to place? We make it simple. Complete the form, accept the terms and submit. It’s done!

Once your claim(s) are received, we begin preparing an acknowledge report and the claim is forwarded to an account representative to begin the collection process.

Download this form for PDF

Creditor Information
Debtor Information
Debtor Contact Name *
Account Information
*
*

By checking this box I agree to the Terms & Conditions. To review the Terms & Conditions please click here.

I accept the Terms & Conditions *

SUPPORTING DOCUMENTS MUST BE FAXED AFTER SUBMITTING CLAIM

* = Required Fields