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To submit a claim online, please complete the fields shown below. After submittiing the online claim, please ensure you send documentation identifying the debtor and substantiating the debt. This includes bills, invoices, contracts, credit application, work order(s), patient intake/financial responsibility forms, NSF check(s), drivers license and insurance cards. Documents can be scanned and emailed to manager@crmcollect.com; faxed to 516-430-5015; or securely uploaded directly to our server using the file uploader. A link to the uploader can be found at the bottom of this page.

* = Required Field

Debtor Last Name*

Debtor First Name & M.I.*

Debtor SSN (EIN if a business)

Debtor Date of Birth (month day, year)

Co-Debtor Name (additional responsible party)

Co-Debtor SSN

Co-Debtor Date of Birth (month day, year)

Debtor Address*

City*

State*

Zip*

Debtor's Home Phone Number

Debtor's Cell Phone Number

Debtor's Work Phone Number

Debtor's Email

Debtor's Place of Employment

Debtor's Employment Address

If Co-Debtor's address, phone or employment is different, please provide it in the "Comments" box.

Client Name* (company or representative submitting claim)

Creditor Name* (company or individual owed the money)

Submitter's Email

Amount Due*

Is this a court judgment?

YesNo

Debtor's Account # at Your Business

Last Date of Service (mm/dd/yyyy)*

Original Payment Due Date for Last Date of Service (mm/dd/yyyy)*

Has this account previously been in Collections?*

YesNo

Has this account been Charged-Off?*

YesNo

>>> For Medical Debt Clients:

Did the debtor/patient keep insurance payments?

YesNo

Amount insurance company remitted to debtor/patient

Insurance Company Name

Comments (additional addresses, phone no.'s, maiden name or aliases, etc.)

Please choose how you are assigning this account.*
For contingency fee pricing the minimum account value is $500.00.
For flat fee pricing the maximum account value is $1000.00.

Contingency Fee PricingFlat Fee Pricing^

By submitting this form, I/we assign to C.R.M. this account for debt collection in accordance with the Terms and Conditions of Collection Services and affirmatively confirm that the individual providing this information is the lawful agent of the Creditor and can bind said Creditor for collection purposes.

Full Name of person submitting this account*

Please review your entries before clicking the Submit button, especially the SSN and Date of Birth fields.

>>> Don't forget to send us your documents validating this debt. <<<
^Payment for Flat Fee accounts is required prior to the commencement of collection services.

After clicking the Submit Claim button above to send the online claim form, be sure to upload your files and documents related to the debt you are assigning to CRM.  Clicking the button below will take you to the file upload portal:

File Upload Portal