WILLIAMS & WILLIAMS ONLINE CLAIM FORM

The instruction below provides you with a copy of your placement. Immediately after submitting, fax or email 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 email placements to Williams & Williams, Inc. Note the following steps:

FAX OR EMAIL: • Fill in the blanks • Print form from your computer • Click "Reset" • Fax or email 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:
Email Addresses:
Bus. #:
Fax #:
Cell #:
Prin. Name:
Res. Street Add.:
City/State/Zip:
Res. Phone:

We would appreciate any additional information that you feel would be helpful:
Print this filled placement form now for a hard copy. Submit your form electronically by clicking "Submit" below. Alternatively, fax the printed form to 502-451-7490. Be sure to email or fax your supporting documentation. "Reset" will erase all information and the placement will be cancelled.
Placement constitutes acceptance of Williams & Williams, Inc. terms and conditions as stated at its website of www.collectthemoney.com

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