Commercial Claim Form

Insurance Claim Form

Pay by Credit/Debit Card

Pay by E-check

Commercial Claim Form

ATTN CLIENTS: THIS FORM IS FOR COMMERCIAL USE ONLY. IF YOU ARE AN INSURANCE COMPANY PLEASE FILL OUT THE INSURANCE CLAIM FORMS.

If you have received any direct payments notify us with a payment notification.

COMMERCIAL CLAIM FORM
Immediate Collection Date
Debtor
Address
City
State
Zip
Amount for Collection $
Invoice #
Invoice Dates (required)
Contact Person
Telephone
Fax  #
Office #
Debtors Bank
Acct #
Enclosures: INVOICES
NSF CHECK
STATEMENT
CREDIT REPORT
LETTERS
Additional Info:
   
Creditor:
Creditor ADDRESS:
Creditor CITY:
Creditor STATE:
Creditor ZIP:
Creditor TELEPHONE:
Creditor FAX:
Creditor Email:
SUBMITTED BY:
 
HARRIS, KLEIN ASSOCIATES, INC.
224 CREEKSTONE RIDGE WOODSTOCK, GA 30188
OFFICE: 770-591-7499 - 1-800-440-1452 - FAX: 770-924-2289 - 1-800-692-1601