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Insurance Mitigation
Report Request

Client Information

New clients, please complete this entire section.
Returning clients, please ensure that your company name is on the first line.

* Indicates a mandatory field.

 

Please enter your name.
Please enter a valid email address.Please enter a valid email address.

 

Debtor Information

* Indicates a mandatory field.

 

Please enter the Debtor's name.
Please enter the Debtor's address.
Required.
Please select an item.
Required.
Required.Please enter a numeric value. Required.Please enter a numeric value.
A value is required.Please enter a valid email address.

 

Claim Information

* Indicates a mandatory field.

 

Please enter an amount.Please enter a numeric value. 
% per year.
Client must have documentation showing this rate (credit application, purchase order, contract, invoice, statement of account, etc.).

,
,

   
 

Please provide a brief explanation in the Comments box below.

 

Insurance Status (Form 6)

* Indicates a mandatory field.

 

Please enter the name of your insurer.

Please choose Yes or No.

 

Additional Comments

 

 

Terms & Conditions

 

The Following Terms And Conditions Will Apply To All Services:

  1. All claims submitted to ACA verbally, in writing, or by email are subject to the same terms and conditions. It is the client’s responsibility to read and understand these terms and conditions.
  2. All claims are placed for a minimum fixed period of 180 days unless otherwise indicated on the Placement Form for a particular service. After the initial 180 day period, the client may request cancellation of the claim by providing written notice. The file will be closed 90 days from the date of that notice. All monies collected are subject to ACA’s Regular Commission Rates.
  3. All monies will be held In Trust, and the client authorizes ACA to endorse cheques (or any other negotiable instruments) for deposit into said Trust Account(s).
  4. Should the client withdraw a file prior to the end of the fixed period described in “2)” above, it is agreed that ACA will be compensated for all work performed on said file, not to exceed 50% of the commission regularly charged had the matter been collected in full.
  5. Collections include all payments received by ACA, the client, any credits issued or agreed to by the client and the debtor, any contra transactions between the client and the debtor and any other amounts resulting in the reduction of the debt.
  6. The client agrees to advise ACA immediately of any collections as described in “5)” above.
  7. Any amounts, with respect to any claim placed with ACA, paid to a party other than ACA, its Legal counsel, the client or in some cases the client’s client, will be subject to Regular Commission Rates.
  8. If, through the efforts of ACA, it is determined that the claim placed with ACA is incorrect due to prior payments, returned merchandise or any credit notes not reflected in the client’s documentation, the amounts in question will be subject to the Regular Commission Rates.
  9. At the discretion of ACA and at ACA’s expense, a Legal Demand Letter may be sent to the debtor on the client’s behalf, by attorneys designated by ACA.
  10. Legal proceedings, other than those mentioned in “9)” above will not be commenced unless the client agrees in writing. When legal proceedings are recommended, the client will be advised of the potential fees and/or options involved as well as any deposits that may be required.
    The client agrees to provide all necessary documentation, as well as to make available (if required) a viable witness who has direct knowledge of the situation in question.
  11. Claims previously placed with another collection agency (or attorney), will be considered Reassigned, and commissionable at a rate of 50% of the amount collected.
  12. The debtor may be charged interest accrued from the due date of the debt in question, at a rate agreed upon by the parties, or at the allowable interest rate of the province or state in which the debtor receives mail. These monies may be waived, retained by ACA to offset expenses incurred, or remitted, at ACA’s discretion.
  13. Should the client reject a bona fide settlement offer of which ACA recommended acceptance, and then settles (at a later date) for less than that amount (or zero), ACA reserves the right to charge the client full commission on the rejected settlement amount.
  14. ACA reserves the right to recover from the client, all (or a portion of) bank charges levied against them (ACA) due to NSF activity stemming from an individual debtor.
  15. Any changes to these terms and conditions must be completed in writing, and agreed to by all parties.

Completing all steps online resulting in the Submission of an account to ACA, signifies the client’s acceptance of the Terms & Conditions as they apply to that specific collection matter.

 

I accept the terms and conditions listed above. *
You must agree to the Terms and Conditions by checking the box above.

 

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