Coastal Customer/Creditor Information

    First Name: 
     Last Name: 
         Title: 
       Company: 
Street Address: 
          City: 
         State: 
      Zip Code: 
     Telephone: 
           FAX: 
        E-mail: 
           URL: 

Supply the following information relating to you and your company:
Do not complete if you are a new customer to Coastal.

Customer Number

Employee Number

Debtor (Your Customer) Information

Select the service you would like:

Immediate Collection 15-Day Demand Letters Only Review Only and Call Me

 

Debtor Information

Company Name 
Owner/Principal  
   Contact Name  
           Address1  
           Address2  
    City/State/Zip  
               Phone  Fax  
       Customer #  E-mail  
   Debtor's Bank  
      Bank Phone 

Debtor is a:	 Corporation	 Partnership	 Sole Proprietorship 

Claim Information

Amount of Debt			
Date of Oldest Invoice	
Date of Last Payment	

Terms of Sale:		 Open Account	 Letter of Credit 

Did buyer receive goods?				Yes 	No 
Did buyer receive Bill of Lading (title documents)?	Yes 	No 

Please mark all that apply:   Broken PromisesNSF ChecksIgnores DemandsPersonal GuaranteeUnable to ContactValid DisputeInvalid Dispute
(To select more than one:  hold down CONTROL and click with mouse)

Other (please specify)	

I have access to the following documents that prove or secure my claim:

Invoices  Credit Application  Guarantee   Bank Info
Checks    UCC Filing Statement of Account Other
Call Log  Outline of Dispute  Bond Rights Lien Rights
Purchase Order Signed Contract Unsigned Contract
Time Sheet or Service Call 

				
I will be forwarding the following documents	NoneStatement of AccountInvoicesPurchase OrdersDishonored ChecksCorrespondenceCredit ReportArbitration AwardPersonal GuarantyOriginal Bill of ExchangeSubrogation AgreementOther
(To select more than one:  hold down CONTROL and click with mouse)
	 by Mail	 by Fax
	
Comments or Special Instructions  

Please read the following before sending this form.

I have read Coastal's Terms and Conditions and agree to place this claim for collection subject to these Terms and Conditions.
 

Form Submission