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TYPE OF CLAIM: Commercial Claim Retail/Consumer Transportation Insurance

Debtor Information:
       Debtor Name:
Person to Contact:
                Address:
                      City:     State:     Zip:-

        Area Code:    Phone: -    Fax:-

    Principal Amount Due: $. 
    Account Number that you use to identify your customer:

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It is agreed that the fee for this claim will be either CLLA plus a 5% non-contingent suit fee, or alternative rate structure.  It is understood that commissions will be charged on all accounts collected, paid direct, withdrawn, or settled by the return of merchandise.

Creditor Information:
    Your company name:
                    Your name:
                        Address:
                               City:     State:    Zip:-

Area Code:  Phone:-      Fax:-   by internet: