Submission Form:
Who are we collecting from? Business or Consumer:
Please Select
Business
Person
Back
Next
Debtor Information
Name of Debtor or Contact Person if Business
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal
Phone Number:
*
If no Phone Number, please enter last known number
Format: (000) 000-0000.
E-mail:
*
If you don't have one, please write N/A
Name of Business (Only if we are collecting from the business)
Company Name
Back
Next
Debt Details
Balance Due:
*
Invoice Date
*
-
Month
-
Day
Year
Last Payment Date (leave blank if none)
-
Month
-
Day
Year
Any Dispute on File?
*
Yes
No
Please provide your last communication and any important notes regarding your customer and the reason they have not paid or if there any additional phone numbers or emails
*
Back
Next
Your Company Info
Your Name
First Name
Last Name
Your Company Name
*
Use same name as per your Collection Agreement
Your Phone
*
Use the same phone as your signed Collection Agreement
Format: (000) 000-0000.
Your Email
*
***Use the original email from the collection agreement
Back
Next
Your Account Number (not mandatory) :
Your Company Info
Back
Next
Authorization & Submit
We authorize ICON to begin collections as of today. If the debtor contacts us, we will redirect them to ICON and report any payments received immediately.All information provided is accurate, with no additional fees added beyond any applicable interest. We understand that while the account is with ICON, we will not communicate with the customer.
*
Other Phone Numbers
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth:
DOB if you have otherwise leave blank
Invoice Date:
*
Last Payment Date (leave blank if none)
Date of Birth:
-
Month
-
Day
Year
DOB if you have otherwise leave blank
Social Insurance Number:
Sin# if you have otherwise leave blank
Is there more than one debtor on Invoice?
Please Select
Yes
No
If Yes Please add them below
Name of Co-Debtor if applicable
First Name
Last Name
Authorization Statement
*
File Upload
*
Browse Files
Drag and drop files here
Choose a file
pdf, jpg, jpeg, png
Cancel
of
Promo Code (if applicable)
Submit
Should be Empty: