Claim Forwarders - Your Collection Network - Portfolio Information Form

A/R Portfolio Information Form

Please Fill In Your / Company Information Here

Business Name Contact

Address 1 Address 2

City State Zip Code

Select The Country You Are In

Phone Cell Phone Fax

Email Address Web Address

Information On Debt Portfolio To Place For Collection

Total Debt To Place Number of Accounts

Description of Debts Preferred Contingent Rate

Accounts Placed Monthly Average Age of Debt

General Location of Debtors - City State

Select The Country Where The Debtors Are

Please Check All That Apply For The Receivables You Wish To Place

Written Contract Oral Contract Judgment Promissory Note Loan

Short Term Note Long Term Note In-House Credit Plan

Have you ever placed any of these receivables with a collection provider previously?

Special Requirements Of Collection Provider or Additional Comments

Terms and Conditions For Use Of Our Website and Network Recommendations

By submitting this form, I understand that Claim Forwarders will match my debt portfolio with the member of their collection network who represents the most viable candidate to collect it. By submitting this form to Claim Forwarders, I am under no obligation to use their network member to collect my debt portfolio, nor am I under any obligation to pay Claim Forwarders for the analysis nor the selection of their network member that they recommend. I also understand that in the event that I choose to engage or contract with the selected network member as recommended by Claim Forwarders, that I will hold Claim Forwarders and it's employees harmless of any liability associated with the selected or recommended company for which I have elected to place accounts receivable with or have chosen of my own free will to conduct business with.