Let’s get started. Our claim placement form allows you to quickly submit a claim online. Only fields with a * must be completed. Please email any documents you have with your claim to info@losangelesdebtcollectionagency.com

Your Company Name

Your Company Point of Contact

Your Company Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Company Phone Number

(###)

###

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Your Company Email

Debtor Name

Debtor Point of Contact

Principal Amount Due

Interest/Late Fees/Collection Fees Due:

Date of Oldest Open Invoice

YYYY

Last Payment Date

YYYY

Last Payment Amount

Debtor SSN or EIN #

Debtor Phone Number 1

(###)

###

####

Debtor Phone Number 2

(###)

###

####

Debtor Phone Number 3

(###)

###

####

Debtor Phone Number 4

(###)

###

####

Debtor Email 1

Debtor Email 2

Debtor Address 1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Claim Information

Placement Form

Let’s get started. Our claim placement form allows you to quickly submit a claim online. Only fields with a * must be completed. Please email any documents you have with your claim to info@losangelesdebtcollectionagency.com