WILLIAMS & WILLIAMS ONLINE CLAIM FORM

The instruction below provides you with a copy of your placement. Immediately after submitting, fax us the pertinent backup documentation, as we will be anticipating its receipt:

SUBMIT ONLINE: • Fill in the blanks • Print form from your computer • Click "Submit" • Fax backup

This WWI Online Claim Form may also be used to fax or mail placements to Williams & Williams, Inc. Note the following steps:

FAX OR MAIL: • Fill in the blanks • Print form from your computer • Click "Reset" • Fax or Mail everything

Client / Creditor Information: Current Clients - 1st and last 2 lines only
Co. DBA:
Bus. Legal Name:
Mailing Address:
City/State/Zip:
Direct Phone #:
Direct Fax #:
By/Title:
Email Address:

Debtor Information: Include all debtor locations and Business Phone #s. "Your Customer #" is the ID# or ACCT# used by your company to reference this account.
Claim Amount:
Oldest Inv. Date:
Your Customer #:
Debtor's DBA's
Bus. Legal Name:
Street Address:
City/State/Zip:
Contact Names:
Bus. #:
Fax #:
Cell #:
Prin. Name:
Res. Street Add.:
City/State/Zip:
Res. Phone:

Choose One:	Immediate Collection	Free Demand Option
We would appreciate any additional information that you feel would be helpful:
For a copy of this filled in placement form, activate your "printer" now! If you choose to transmit your claim via the Internet, click "Submit" and then fax supporting documentation now to (502) 451-7490. If you select "Reset" before "Submit" all information will be erased and the placement cancelled.

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