UHG | Refer Account for Legal Review

1
Service Provider Name* This field is required.
Enter the name of your agency
2
Requester's Email
example@example.com
3
UHG Account #:* This field is required.
Please enter exact as it was placed with you.
4
Issuer Name* This field is required.
Please enter exact as it was placed with you.
5
Consumer Name* This field is required.
First Name
Last Name
6
Consumer State* This field is required.
select state
select state
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
7
Charge-Off Date* This field is required.
Date
Month
Day
Year
8
Current Balance:* This field is required.
9
Consumer's Assetsoptional
if known
10
Consumer's Current Bankoptional
if known
11
Consumer's Current Employeroptional
if known
12
Please provide any other reasons you are referring this account for Legal Action.
Huge
Large
Normal
Small
Ok
Ok
13
UHG Comments-Internal
Huge
Large
Normal
Small
Ok
Ok
14
Get Page URL
Should be Empty: