This document is a debtor placement form for a collection agency. It requests information about the debtor such as company details, contact information, bank account numbers, and previous collection experience. It also requests information about the creditor placing the debt such as company name, address, phone number, and authorized representative. The form notes that international cases are always considered immediate collection and that the collection agency has authority to endorse and negotiate checks on behalf of the creditor.

1. 1200 Arlington Heights Road
Suite 410, Itasca, IL 60143-2625
Ph: 888/283-8718
Fax: 630/931-4830
DEBTOR PLACEMENT FORM
Date: Amount: $ Currency: (If not in U.S. Dollars)
Immediate Collection (Int’l cases are always considered immediate, except Canada and Puerto Rico.)
Second placement (previously placed with another collection agency or attorney
All claims are subject to the Atradius Collections standard rate schedule or agreed upon rates. Forwarder agrees Atradius Collections can refer an account to a collection attorney, if
necessary. Atradius Collections has the authority to endorse and negotiate checks payable to the creditor and deduct fees and authorized charges. Unless indicated otherwise this
claim will be considered an immediate placement.
Debtor Information:
Debtor Company:
Address:
City: State: Zip/Post Code: Country:
Contact: Title:
Phone Number: Cell Number:
Fax: E-mail Address:
Languages spoken (Int’l debtors only):
Bank Information: Bank Account Number:
Debtor Composition: Corporation Partnership Individual Other
Enclosures: Statement Invoice NSF Check Correspondence Other
* Backup invoices are requested for all cases, and are required for international cases.
Comments/Experience:
Creditor Information:
Your Company Name:
Address:
City: State: Zip:
Phone: E-mail: Fax:
Your Account / Reference No.:
Authorized By:
PLEASE COMPLETE AND RETURN TO:
TED SILBERG / REGIONAL MANAGER
TED.SILBERG@ATRADIUS.COM / Phone: 630-499-9850 - Fax: 630-328-8550