Online Debt Collection Claim Form

Claim Placement Form

Click here for a downloadable claim placement form (.pdf), or place a claim using the online form, below.


Includes automatic Ten Day Free Demand Letter. If legal action is required, claims qualifying for less than Regular Rates are forwarded as follows: 25% 1st $2,000.00, 20% excess. Minimum claim: $500.00.

PLEASE PROVIDE ALL PERTINENT DOCUMENTATION INCLUDING STATEMENT OR AGING, INVOICES (IF NOT VOLUMINOUS), CONTRACT, GUARANTY(S), CREDIT APPLICATION, AND CHECK COPIES, AS AVAILABLE.

If you are unable to fill in a field, please enter “n/a” into the field instead of leaving it blank.


  • In the event the account placed for collection herewith cannot be collected by the direct negotiations of your staff, and if we do not designate an attorney herein, you are hereby authorized and instructed as our agent to forward the claim to an attorney or firm of attorneys in our behalf. Such attorneys shall at all times be subject to our control and direction, and no attorney shall commence any legal proceedings without our prior authorization. You are hereby authorized to endorse for deposit and collection, in our name and in our behalf remittances received on this account.
  • Drop files here or
    * you can upload upto 5 files and each file must not exceed 10MB.

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Commercial Receivers Incorporated
P.O. Box 3180
Glen Allen, VA 23058-3180

804-346-0302  X 226

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