Submit a Claim

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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:*
Your Debtor Information 
Debtor Type:
Debtor Company Name:
Debtor First Name:
Debtor Last Name:
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Fax Number:
Email Address:
Amount Owed:
Date Debt Incurred:
Tax ID or SS Number:
Was there a signed Contract?  Yes No
Do You Have Backup Such As Invoices:  Yes No
Is This A Judgment:?  Yes No
If Yes, Date Judgment Was Awarded:
Product Or Service Provided:
Reason for Non-Payment:
Additional Information:

Terms of Service Agreement

THIS AGREEMENT IS MADE BETWEEN Accounts Receivable & ,
Agent of HEREIN REFERRED TO AS CLIENT.

1. Upon placement of a claim(s), where a Debtor owes funds to CLIENT, Accounts Receivable will use its best efforts to expeditiously collect the claim on behalf of CLIENT. Accounts Receivable agrees to charge a commission only on funds actually paid by the Debtor or on the debtor’s behalf to Accounts Receivable or the Client and not the actual amount owed, subject to the provisions of paragraphs 4, 5 and 7 below.

2. CLIENT warrants the validity, amount and authenticity of all claims and accounts placed with Accounts Receivable for collection. Upon request by Accounts Receivable, CLIENT agrees to forward documentation to Accounts Receivable to prove the amount, and authenticity of the claim when requested.

3. Accounts Receivable shall notify CLIENT of any settlement offers received by Accounts Receivable and no settlement offer shall be accepted by Accounts Receivable without CLIENT’S expressed consent.

4. CLIENT may withdraw a claim placed with Accounts Receivable only where a) there has been no activity on the account in the preceding sixty (60) days and b) the claim is not in litigation or involved in an insolvency proceeding. All withdrawals must be done via fax to 1-877-730-5805 by CLIENT and any commission then due and payable to Accounts Receivable must be paid before the claim is deemed withdrawn. Any claim canceled by CLIENT while payments are being made by debtor will be billed by Accounts Receivable for the full anticipated commission due Accounts Receivable on the entire amount of the original claim assigned to Accounts Receivable. There is a fee of 10% of the principal balance of the account for administrative, initiation and clerical expense on all accounts withdrawn by CLIENT not in accordance with the provisions of paragraph 4a and 4b.

5. CLIENT shall report all direct payments made by Debtor to CLIENT to within three (3) business days of receipt of payment by CLIENT via fax to 1-877-730-5805, and the commission due Accounts Receivable on the direct payment shall be remitted to Accounts Receivable within (21) days.

6. All claims placed with Accounts Receivable by CLIENT, regardless of amount, previous collection efforts or nation of Debtor shall be billed by Accounts Receivable to CLIENT at a rate of 30% of any and all funds collected by Accounts Receivable. All claims placed with Accounts Receivable by CLIENT that are over one (1) year in age shall be billed by Accounts Receivable to CLIENT at a rate of 40% of any and all funds collected by Accounts Receivable. Any claim, under $1000.00 in amount owed or claim regardless of age that requires litigation shall be collected at a rate of 50%. Accounts Receivable is entitled to their full commission due on any payments received by the client once the claim is submitted.

7. Any merchandise returned to CLIENT by Debtor after initial contact by shall entitle Accounts Receivable to a commission equal to 10% of the actual invoiced amount when equipment was purchased.

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

9. Accounts Receivable shall account to CLIENT on a monthly basis all funds collected by Accounts Receivable on CLIENT’S behalf and all remittances and/or invoices will be sent at this time.

10. CLIENT grants to Accounts Receivable and to any attorney or collection firm that may forward clients case to 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 Accounts Receivable under this agreement.

11. CLIENT understands that Accounts Receivable may at their discretion forward a case or a claim to an outside law firm or collection network to assist in the recovery of said account and hereby grants Accounts Receivable 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.

12. In no event shall Accounts Receivable be liable in any respect for the inability to collect any account placed with by CLIENT for collection. It is understood and agreed that Accounts Receivable is not a guarantor of any specific result on accounts placed by CLIENT.

13. Accounts Receivable agrees and shall hold harmless CLIENT from any claim, demand, action, cost or judgment, including a reasonable attorney’s fee arising out of any action done or failing to be done by in connection with the collection of any claim(s) place with by CLIENT for collection.

14. 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:*