Welcome! This is where you provide us with the necessary information needed to begin actively pursuing your overdue accounts.

Please fill out ALL information below:

Account Information
Debtor Company Name
Contact
Address
City
State
Zip Code
Phone
Alternative Phone
E-mail
Balance Due
Interest
Other Charges
Accumulated Total Due
   
Oldest Open Invoice Date
Invoice Number
Customer Reference Number
   
Intensity Level
Comments
(check all that apply)
Broken Promises for Payment
Avoids contact, does not return calls
Answering machine or services; cannot contact directly
Disputing balance due
NSF checks received 
(Amount )

Other

Your Client Information
Company
Contact
Address
City
State
Zip Code
Phone
E-mail
   
Authorized By
Date

**Authorization is granted to Clovis & Roché, Inc. to proceed with the recovery of all accounts placed by the company listed above (Client).  Payment made to client's office from the accounts placed for collection will be reported to Clovis & Roché, Inc. upon receipt.  Written approval is required to negotiate settlement or enter into litigation.  Authority is granted to Clovis & Roché, Inc. to endorse any checks, money orders, and like instruments for deposit received from accounts placed for recovery by Client. Authority is granted for Clovis & Roché, Inc. to represent the Client for affidavits needed when litigating accounts placed for recovery by Client. Clovis & Roché, Inc. is due fees on funds recovered commencing the first day of placement of the account. Any deviation from the published rates must be in writing and approved and signed by both parties. An account may be cancelled 30 days after receipt of written notification unless payment arrangements have been established.

 
 

 

©2006 Clovis & Roché, Inc.