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Online Claim Form

Fill out the following form to submit a claim online. You may also Download Alternate Printable Versions of this Form if you prefer. * Denotes required fields.

Client Info
Please provide us with your contact information so that we may reach you upon collection of this claim, or if we have any further questions.
*Company: 
Address1: 
Address2: 
*City:  *State:  Zip:  +4 (optional): 
Company Contact Person
First Name: 
Last Name: 
*Email: 
Fax: ()--  Phone: ()--  Ext.(optional): 
Claimant Info
Please provide as much information as possible regarding the claimant to help us resolve the account for you more effectively. This is especially helpful in claims that require skip tracing.
Company: 
First Name:  Middle Name/Initial:  Last Name: 
Phone: ()-- Address1: 
Address2: 
City:  State:  Zip:  +4: 

Claim Information

*Placement  First Placement  Second Placement  Other
*Loss Date (mm/dd/yyyy):  *Principal$:  *Total$: 
Insured: 
Policy Number:  Claim Number: 

Passive Accounts

Find out about our Passive Account System.
Pay desk or passive file:  Yes  No
Copy and paste the details of your pay desk agreement:
Return Information
*Return by:   Email 
Additional Information or Comments:

Submit Form

 

Mail: P.O. Box 3029 - Kirkland, WA - 98083-3029
Phone: (425) 820-3321 - Toll Free: (800) 258-4370 - Fax: (425) 821-3106
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American Collector's Association National Association of Subrogation Professionals