On-Line Placement Form

There are several ways to place an account for collections:
  1. Download our listing sheet (click here) and e-mail, fax, or mail the form to our office.
  2. Submit your own forms (copies of statements, ledger cards, or computer print-outs) or send us an Excel spreadsheet with your customers information.
  3. Place your accounts for collections over the phone by contacting Client Services at:  605-341-DEBT (3328).
  4. Use our on-line placement form below.

To establish an account and receive a password contact our office or e-mail our sales department at:  sales@expresscollections.com
(please include your business name, address, and phone number).

* Required Information

Client Information
Client Number:
*Client Name:
*Password:
*Submitters Name:
*Submitters Email:
Collection Format
Express Demand Letter (optional): Yes No
Report Account to Credit Bureau (optional): Yes No
(accounts will be reported unless otherwise specified)
Debtor Information
Your Account #:
*First Name:
  MI:
*Last Name:
*Last Address:
*City:
*State: *Zip:
Phone #:
Employer:
Employer Phone #:
Soc. Sec. #:
D.O.B.:
Spouse / Co-signor / Responsible Party Information
First Name:
  MI:
Last Name:
Relationship:
Is the co-signor address same as debtor?  Yes No
* (if not, please complete corresponding information below)
*Co-signor Addr:
*Co-signor City:
State: Zip:
Employer:
Employer Phone #:
Soc. Sec. #:
D.O.B.:
Additional Information  (small claims information, relatives, assets, etc.)
 
Does the account have a judgment?  Yes No
(if yes, please include the judgment date, county, and file number in the additional information field above)
Account Information
*Date Last Charge:
Date Last Payment:
Date Interest to (if added):
Principle:
Interest (if added):
*Total Amount Due:
   
 

This account is assigned to Express Collections with full power and authority to do and perform all acts necessary for the collection, settlement, compromise or satisfaction of said account.

By submitting this claim the above client agrees to all terms of Express Collections including rates and policies.

1141 Deadwood Ave., Suite #9 - P.O. Box 9307 • Rapid City, SD 57709 • 605-343-1311 • Fax: 605-342-7195