Collection Submission Form

Submission Form:

You can also enter your accounts through your Online Client Portal
You are a client of ICON and a Collection Agreement has been submitted to ICON, prior to submitting this account. (all boxes must be read and checked)*

Balance is at least $100You are a client of ICON and a Collection Agreement has been submitted to ICON, prior to submitting this account.You are to REDIRECT your debtors back to ICON for resolution and payment, avoid making any arrangements with them.You MUST report any direct payments made to you immediatelyYou understand that if you cancel for ANY reason in under 1 year that ICON will charge you your FULL FEE on full amount placed for collection as per your contract.You understand that ICON will NOT be reporting regular updates unless we are reporting a payment or need additional information. You are able to log in to your portal to see activity.By providing your contact information you agree to receive phone calls, text messages, and emails about your request, notifications, and promotions. Message and data rates may apply. Upon receiving messages, you may reply STOP to unsubscribe or HELP for assistance."
We have read the above and agree to the terms.

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Who are we collecting from? Business or Consumer:
Name of Debtor or Contact Person if Business*

First NameLast Name
Name of Business (Only if we are collecting from the business)
Company Name
Address*

Street Address

Street Address Line 2

City Province

Postal
Phone Number
If no Phone Number, please enter last known number
E-mail
example@example.com
Date of Birth
DOB if you have otherwise leave blank
Social Insurance Number
Sin# if you have otherwise leave blank
Balance Due*
Invoice Date*
Last Payment Date (leave blank if none)
File Upload*

Cancelof
Any Dispute on File?*

YesNo
Please provide your last communication and any important notes regarding your customer and the reason they have not paid:*
We authorize ICON to start collecting as of today, and if our debtor reaches out to us after this file is submitted to ICON, we will redirect them back to ICON and also report any payments received right away. All the information provided is accurate, and no collection fee is added to the invoices or extra charges over and beyond the original invoice to your customer other than the interest on your original invoice.*

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Your Company Name*
Use same name as per your Collection Agreement
Your Name

First NameLast Name
Your Phone*
Use the same phone as your signed Collection Agreement
Your Email*
***Use the original email from the collection agreement
Reminder:

CLIENTS ARE STRICTLY PROHIBITED FROM COMMUNICATING OR NEGOTIATING DIRECTLY WITH THE CONSUMER, PLACING THE FILE WITH ANOTHER AGENCY, OR ENGAGING IN ANY FORM OF DIRECT INTERACTION WITH THE CONSUMER. ALL CONSUMER INQUIRIES MUST BE REFERRED BACK TO ICON, AND ICON MUST BE NOTIFIED IMMEDIATELY VIA EMAIL salesteam@iconcollectionsolutions.com
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Submission Form: