Submission Form:
Who are we collecting from? Business or Consumer:
Please Select
Business
Person
Name of Debtor or Contact Person if Business
*
First Name
Last Name
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
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
Format: (000) 000-0000.
Other Phone Numbers
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail:
example@example.com
Date of Birth:
DOB if you have otherwise leave blank
Date of Birth:
-
Month
-
Day
Year
DOB if you have otherwise leave blank
Social Insurance Number:
Sin# if you have otherwise leave blank
Balance Due:
*
Invoice Date:
*
Invoice Date
*
-
Month
-
Day
Year
Your Account Number (not mandatory) :
Last Payment Date (leave blank if none)
Last Payment Date (leave blank if none)
-
Month
-
Day
Year
File Upload
*
Browse Files
Drag and drop files here
Choose a file
pdf, jpg, jpeg, png
Cancel
of
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
*
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.
*
Your Company Name
*
Use same name as per your Collection Agreement
Your Name
First Name
Last Name
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
Promo Code (if applicable)
Submit
Should be Empty: