FasTrac Claim Placement Form

Complete the Form below and submit.
You will receive immediate verification of your claim placement.

New clients, contact us before submitting claims -
Mary Mausbach, Operations Manager
800-456-5770

Creditor Information

* Required fields

Creditor Name: *

Contact Name: *

Address:

City, State, Zip:

Country:

Phone:

Fax:

E-Mail: *

Debtor Information

Debtor Company Name:

Debtor Contact Name: *

Debtor Address:

City, State, Zip:

Country:

Debtor Phone: *

Debtor Fax:

Debtor E-mail:

Debtor Social Security #:

First Date of Delinquency:
(00/00/0000)

Claim Amount: (USD) *

Comments/
Explanations:

THANK YOU!

FasTrac Prompt Payment Systems (SM) is a Service of Allied National, Inc.
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