Commercial Claim Placement Form - created by phpFormGenerator

Ross, Stuart & Dawson - Commercial Claim Placement Form

* Asterisk Indicates Required Fields

Debtor Company Name *
Debtor Street Address *
Debtor Suite, Apt #, Floor, Etc.
Debtor City *
Debtor State *
Debtor Zip / Postal Code *
Debtor Phone *
Debtor Cell Phone
Debtor Fax Number
Debtor Email Address
Debtors Account Number *
Debtor Total Amount Due $ *
Debtor Invoice Date (Oldest) *
Debtor FED Tax # / Social Security #
Debtor Contact Name *
Debtor Contact Title *
Debtor Bank Name
Debtor Bank Account Number
Debtor History - Check All That Apply *Claims Inability To PayMail ReturnedDisputedCheck ReturnedNo ResponsePhone Disconnected
Additional Information / Comments
Document Checklist * Please send all documents to RSD via email, fax or U.S. Mail.Personal Guarantees, Notes, etc.Proof of Delivery/Receipts, etc.Statement copiesInvoice(s) copiesSigned Contract/P.O./Credit Application, etc.Credit report
Creditor Info - RSD Client Name *
Claim Submitted By *
Street Address *
Suite, Apt#, Floor, Etc.
City *
State *
Zip / Postal Code *
Phone Number *
Email Address *
Existing Clients - Please ReadEXISTING CLIENTS: By submitting your claim for collection, you are agreeing to the terms and conditions as set forth in our client agreement for the type of claim placed.
New Clients - Please ReadNEW CLIENTS: If you are a new client and have not entered into an agreement with our agency, an RSD representative will contact you shortly to review our rates, terms and conditions. Should you have any questions regarding this process, please call us at 1-888-701-8181 and we will be happy to assist you.

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