Multiclaims - Submit Multiple Claims

Who Is Your Service Rep?*
Your Information  
*Your Company Name or Client Number:
*(Required) Client Number:
Your First Name:*
Your Last Name:*
Address:*
City:*
State/Province:*
Zip:*
Daytime Phone:*
Evening Phone:
Fax Number:
Email Address:*
Enter Multiple Debtors Below  

*IMPORTANT: To fill out all applicable information, Use the scrollbar below the form table to scroll horizontally or use your (TAB) button on your keyboard to move from one field to another. Please try not to use any commas (,) when entering data. Once completed, this will send a CSV file.
*Do not use debtor place of employment for consumer claims

  • Debtor Type
  • Company Name
  • First Name
  • Last Name
  • Address
  • City
  • State
  • Zip
  • Daytime Phone
  • Evening Phone
  • Fax Number
  • Email Address
  • Debtor Employment
  • Amount Owed
  • Date Debt Incurred
  • Does Debtor Have an Attorney?
  • Attorney Contact Information:
  • Debtor Tax ID or Soc Sec. #
  • Is This A Judgment?
  • If Yes, Date Judgment Was Awarded
  • Product Or Service Provided
  • Reason for Non-Payment
  • Additional Information
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False
  • Yes No
  •  True False