Commercial Claim Form

Insurance Claim Form

Pay by Credit/Debit Card

Pay by E-check

Direct Payment Notification

If you have received a direct payment from the debtor please fill out this form to notify us.
YOUR COMPANY NAME
YOUR ID #
DEBTOR NAME
HKA ID #
AMOUNT PAID $
BALANCE DUE $

COMMENTS:

 
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