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Untitled Document


The more detail you supply in the beginning, the sooner we can get started and the more effective we are likely to be.
   
* denotes required fields
   
* Company
* Contact Name
* City, State, Zip
-
Telephone #
Ext:
Fax #
*E-Mail
 
 
* Company
E-Mail
* Address 1
Address 2
* City, State, Zip
-
* Phone

* Amount of Claim $

 

 

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We hereby authorize you as our agents to collect for us, the claim listed above. We expect you to take any action deemed necessary to protect our interests. We will immediately report all direct remittances from the debtor. We agree that any payments received after the date of this form shall be subject to your published fee schedule and if necessary to offset any monies due to you for outstanding invoices from any proceeds collected. If deemed necessary, you are furthermore authorized as our agents (1) To refer this claim for legal action and invoice us for all Advanced Investigative & Discovery Expenses as outlined in Fee Schedule in addition to executing all necessary documents to prosecute the claim on our behalf and we hereby designate your firm as collection agent for this purpose. In the event this claim becomes a claim in a court of law and there is an answer or counter claim imposed, notification will be given and at that point this agreement can be renegotiated to incorporate additional services that will be necessary. (2) To deposit checks or other negotiable instruments in your escrow account. (3) To enter into any negotiation that may result in collecting the due amount. (4) To assign or re-assign attorneys or forward to other collection agencies as you deem necessary. We further agree (A) Any agreed return of merchandise shall be deemed as money collected and subject to your rate schedule. (B) If claim is withdrawn we understand that we will receive a charge for collection services rendered subject to your rate schedule. (C) Any controversy or claim arising out of or relating to the above authorization or the breach thereof shall be settled by arbitration administered by the American Arbitration Association in New York City under its Commercial Arbitration Rules, and judgment on the award rendered by the Arbitrator may be entered in any court having jurisdiction thereof. By placing this claim via email and/or fax we understand that it is a true submission to you by an authorized person. Please accept this submission as a signed claim.

 

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Alternately, fax a completed form to (516) 487-4538.

 
 

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