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Claim Placement Form

Complete the Form below and submit.
You will receive immediate verification of your claim placement.

This form has been optimized for use in Internet Explorer 4.0+ (and above) and Netscape 4.0+. If you experience difficulty submitting the claim, you can print the Adobe Acrobat pdf printable version of the claim form and fax it to 800-489-4892 or 402.393.3541. Click here for the Allied National Account Placement Form.

Creditor Information
* Required fields

Creditor Name: *

Contact Name: *

Address:

City, State, Zip:

Country:

Phone:

Fax:

E-Mail: *

Debtor Information-Claim 1

Debtor Company Name:

Debtor Contact Name: *

Debtor Address:

City, State, Zip:

Country:

Debtor Phone: *

Debtor Fax:

Debtor E-mail:

Debtor Cell Phone:

Debtor Social Security #:

First Date of Delinquency:
(00/00/0000)

Claim Amount: (USD) *

Comments/
Explanations:

Debtor Information-Claim 2

Debtor Company Name:

Debtor Contact Name: *

Debtor Address:

City, State, Zip:

Country:

Debtor Phone: *

Debtor Fax:

Debtor E-mail:

Debtor Cell Phone:

Debtor Social Security #:

First Date of Delinquency:
(00/00/0000)

Claim Amount: (USD) *

Comments/
Explanations:

Debtor Information-Claim 3

Debtor Company Name:

Debtor Contact Name: *

Debtor Address:

City, State, Zip:

Country:

Debtor Phone: *

Debtor Fax:

Debtor E-mail:

Debtor Cell Phone:

Debtor Social Security #:

First Date of Delinquency:
(00/00/0000)

Claim Amount: (USD) *

Comments/
Explanations:

Debtor Information-Claim 4

Debtor Company Name:

Debtor Contact Name: *

Debtor Address:

City, State, Zip:

Country:

Debtor Phone: *

Debtor Fax:

Debtor E-mail:

Debtor Cell Phone:

Debtor Social Security #:

First Date of Delinquency:
(00/00/0000)

Claim Amount: (USD) *

Comments/
Explanations:

Debtor Information-Claim 5

Debtor Company Name:

Debtor Contact Name: *

Debtor Address:

City, State, Zip:

Country:

Debtor Phone: *

Debtor Fax:

Debtor E-mail:

Debtor Cell Phone:

Debtor Social Security #:

First Date of Delinquency:
(00/00/0000)

Claim Amount: (USD) *

Comments/
Explanations:

THANK YOU!
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Collection Services Agreement.


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