Submission Form:
Who are we collecting from? Business or Consumer:
Please Select
Business
Person
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Debtor Information
Name of Debtor or Contact Person if Business
*
First Name
Last Name
Name of Co-Debtor if applicable
First Name
Last Name
Address: (if the debtor's address is unknown please type "unknown"
Street Address
Street Address Line 2
City
Province
Postal
Phone Number:
*
If no Phone Number, please enter last known number
Format: (000) 000-0000.
Other Number:
If no Phone Number, please enter last known number
Format: (000) 000-0000.
Date of Birth:
-
Month
-
Day
Year
DOB if you have otherwise leave blank
Social Insurance Number:
Sin# if you have otherwise leave blank
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
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Debt Details
Balance Due:
*
Do you charge interest on this account?
*
Yes — and the rate is stated on our invoice or contract
Yes — but it's not stated on our invoice
No
Do you charge interest on overdue accounts?
Yes — the rate is stated on my invoice or contract
Yes — but the rate is NOT stated on my invoice
No
What annual interest rate do you charge? (e.g. 24% per annum)
Invoice Date
*
-
Month
-
Day
Year
Account Eligibility: We do not accept accounts older than three years from the date of the original invoice.
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
*
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Your Company Info
Your Name
First Name
Last Name
Your Company Name
*
Use same name as per your Collection Agreement
Your Email
*
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Authorization & Submit
We authorize ICON to begin collection efforts on this account effective today. Should the debtor contact us directly, we will redirect them to ICON and report any payments we receive immediately. We confirm that all information provided is accurate, that no additional fees have been applied beyond any applicable interest, and that the consumer being placed into collections is over 19 years of age. We understand that, while this account is active with ICON, we will not communicate directly with the customer.
*
Authorization Statement
*
File Upload
*
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Client ID
Promo Code (if applicable)
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