Place a Claim

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DEBTOR INFORMATION
Customer #:
Company Name:
Company Name 2:
Contact Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Debtor is a:
Debtor Bus. Phone/Ext:
Debtor Home Phone:
Debtor Cell Phone:
Debtor Fax Number:
Debtor Email Address:
Debtor Web Address:
Date of Last Payment:
Date of Oldest Invoice: Help Icon
* Amount Due:
CREDITOR INFORMATION
DAL Client ID:
Creditor:
Alias:
Address:
City:
State:
Zip Code:
Creditor Web Address:
Creditor Phone/Ext:
Creditor Fax:
Creditor Cell Phone:
Creditor Contact:
* Creditor Email:
DOCUMENTATION: (check all that apply)
Please note that documentation is required for processing to begin. Documentation provided by you today avoids future requests that can delay our collection efforts.







I will be forwarding documentation by:
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Drag and Drop Files here or Click to Upload File(s)
Maximum of 15 files can be uploaded; Acceptable formats include Word, Excel, PDF, and Zip Files. Total upload: 50 MB (50,000 KB)
Selected File(s):
EXPERIENCE: (check all that apply)





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