Date

CREDITOR INFORMATION

Creditor Name (required)

Account #

Address 1

Address 2

Credit Executive (required)

Phone (required)

Fax

Email (required)

DEBTOR INFORMATION

Debtor (required)

Account #

Customer Reference #

Address 1 (required)

Address 2

Contact Name (required)

Phone (required)

Fax

Date Last Invoice (required)

Date Last Payment

Report to Credit Bureau
yesno

Amount (required)
$

Select Starting Service: (required)
Immediate ActionImmediate Litigation

Supporting Documentation
Itemized StatementCredit ApplicationPersonal GuarantyCredit ReportOriginal ContractPertinent CorrespondenceNSF ChecksNotes or drafts

Date and results of last conversation with Debtor

Upload supporting documents
(We only accept .jpg, .gif, .png, .doc, .docx, .pdf, .txt file formats,
file size limit is 1MB)

If you need to send us more than 3 documents or larger files than are permitted, please contact us directly at 800-457-8244, fax us at 303-806--5360 or email us at claims@msccm.com

By submitting the above account for collection, MSCCM is authorized to commence action against the debtor. You are authorized to accept payment, deposit funds in our name, and to select an attorney if warranted. We agree to abide by MSCCM’s standard fee schedule. No legal action will be filed without our prior consent.