CLAIMS INFORMATION 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: _____________________________

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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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Client File number to reference: ____________________