Multiclaims - Submit Multiple Creditors

Who Is Your Service Rep?*
Your Information  
Your Company Name:
Your First Name:*
Your Last Name:*
Address:*
City:*
State/Province:*
Zip:*
Daytime Phone:*
Evening Phone:
Fax Number:
Email Address:*
Enter Multiple Creditors 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

  • Contact Name
  • Phone Number
  • Amount Owed
  • Amount You Can Settle For Today*
  • Target Settlement**
  • Target 12 Month Payment Plan**

Terms of Service Agreement

THIS AGREEMENT IS MADE BETWEEN ACCOUNTS RECEIVABLE HEREIN REFERRED TO AS A.R. and ,
Agent of HEREIN REFERRED TO AS CLIENT.

1. Upon placement of a claim(s) A.R. will use its best efforts to arrange settlements and reduce the amounts due on claims submitted on behalf of CLIENT through our Solvency Shield Program.

2. CLIENT warrants the validity, amount and authenticity of all claims placed with A.R. for reduction. Upon request CLIENT agrees to forward documentation to A.R. to prove the amount, and authenticity of the claim.

3. CLIENT may withdraw a claim placed with A.R. only where a) there has been no activity on the claim in the preceding sixty (60) days and b) the claim has not been forwarded to an affiliated attorney. All withdrawals must be done via facsimile to 1-877-730-5805 by CLIENT and any commission then due and payable to A.R. must be paid before the claim is deemed withdrawn. Any claim canceled by CLIENT while payments are being made, negotiations are taking place or expected imminently will be billed by A.R. for the full anticipated commission due on the entire amount of the original claim assigned to A.R. There is a fee of 10% of the principal balance of the claim for administrative, initiation and clerical expense on any claim withdrawn by CLIENT not in accordance with the provisions of paragraph 3a and 3b.

4. CLIENT shall report all payments directly to the creditor on claims submitted within three (3) business days of receipt of payment, and the commission due on the direct payment shall be remitted to A.R. within (21) days once a claim is placed with A.R. for Solvency Shield. CLIENT shall instruct contacts made by their creditors and their representatives to direct all communication to A.R.

5. All claims placed with A.R. by CLIENT are billed at a rate of 20% of the total reduced amount of the original claim. Upon reaching a negotiated amount A.R. shall bill CLIENT the total settled amount with the fee charged by A.R. Upon clearance of these funds, they will be distributed to the creditor. In the event that the client agrees to a said reduction but fails to act upon it, they A.R. will still be entitled to its earned fee.

6. Any claim placed with A.R. by CLIENT that is discovered to have been previously paid or placed by CLIENT in error will be billed by A.R. to Client at a rate of 10% of the placed amount as an administrative, clerical and initiation fee.

7. CLIENT understands that A.R. may at their discretion forward a case or a claim to an outside law firm to assist in the negotiation of said claim and hereby grants A.R. permission to do so. It is further understood that CLIENT must give approval in the event that such a transfer will result in additional charges.

8. A.R. shall account to CLIENT on a monthly basis all funds remitted by A.R. on CLIENT’S behalf. CLIENT understands that A.R. will release funds to creditors only once the funds have cleared and will process remittances monthly.

9. CLIENT grants to A.R. and to any affiliated attorney that may be forwarded CLIENT claim(s) the express authority to endorse and negotiate any check, draft or other negotiable instrument made payable to CLIENT for deposit in trust for distribution to CLIENT after deducting the commission and fees due A.R. under this agreement.

10. In no event shall A.R. be liable in any respect for the inability to produce any results on any claim placed by CLIENT. It is understood and agreed that A.R. is not a guarantor of any specific result on accounts placed by CLIENT.

11. A.R. agrees and shall hold harmless CLIENT from any claim, demand, action, or judgment, including all reasonable legal fees arising out of any action done by A.R. in connection with the collection of any claim(s) placed by CLIENT, which is not a result of a violation by CLIENT of any portion of provision 2.

12. This agreement shall be construed in accordance with the laws of the State of Florida. In the event that any provision hereof is found to be invalid or unenforceable, then that provision shall deemed to be severed and removed and the remaining provisions shall remain valid and in full effect.

Agree To Terms of Service

To submit an account for collection, you must agree to our Terms Of Service. By checking the box, you agree and affirm that you have read and understand our Terms Of Service and that you agree to be legally bound by those terms. This agreement applies to each and every account placed with Accounts Receivable for collection regardless of how the account is submitted to our office. You are entering into a legally enforceable contract for the collection of the accounts submitted so do not electronically sign this document if you have any questions.

I have read and agree to all of the terms and conditions outlined in the Terms Of Service. I certify that am authorized to enter into this agreement on my behalf or on behalf of my company. I understand that this is a legal binding agreement that may be enforced through legal action. By typing my name below I am making a lawful electronic signature, capable of enforcement as if I had signed the agreement personally.

Agreed on this Date:*

Authorized Signature:*