To fax or
mail your claim, PRINT this page
TYPE OF CLAIM:
Person to Contact:
Principal Amount Due: $.
Number that you use to identify your customer:
Replace this Text with your notes: Only the viewable portion will print!
It is agreed that the
fee for this claim will be either
CLLA plus a 5% non-contingent suit fee, or
rate structure. It is understood that commissions will be
charged on all accounts collected, paid direct, withdrawn, or settled by the
return of merchandise.
Your company name: