Collection Application for Risk & Insurance
Thank you for your message and interest in our services.

In order to represent you, we need you to complete a collection application. This is for risk and insurance purposes.

Below is the link to our short application. Please review and complete. We will contact you once we have the results.
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Business Name *
Contact Name *
Email *
Address *
Phone number *
Business registration # *
Please provide a brief history of your company (owners, year started). If your company is less than 3 years old, we require credit references. Note: we are unable to represent Real Estate or rental companies. *
Has legal action ever been filed against you (the owner) or a company that you have owned? *
Required
Has you or your company ever been placed in collections? *
Required
Have you ever filed for Bankruptcy? *
Have you ever listed a claim with a collection agency before? If so, who was your previous collection agency? *
Are you a member of any local networking groups? Chamber of Commerce, Trade Associations, Rotary? *
Do you deal with a current law firm? Please list *
Who can we thank for your referral?
I swear that this information is true to the best of my knowledge: (Owner's Name) *
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