Commercial Claims Info Sheet

Date Claim Submitted: __________________

Outstanding Balance Due: ________________

Name of Business: ________________________________________________________

Corporate Owner/Proprietors: _______________________________________________

[ ]  Corporation  [ ]  General Partnership  [ ]  Sole Proprietor   [ ]  LLC Limited Partnership

Business Address: ________________________________________________________

Street City State Zip Code

Phone: ___________________________
Contacts: _____________________________

Billing Address: __________________________________________________________

Street City State Zip Code

Phone: ___________________________
Contacts: _____________________________

Alternate Address/contacts: _________________________________________________

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Enclosures:

[ ] Master Agreement [ ] Copies of Payment/Checks

[ ] Change Order (s)     [ ] Copy of Ad (s)

[ ] Invoices                     [ ] Copy of Proof (s)

[ ] Statement of Account [ ] Correspondence

[ ] Payment History     [ ] Other

[ ] Proof of Mailing/Delivery

Other Information: _________________________________________

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