Single Placement Form

Individual claims can be submitted online using the form below or simply e-mail them to newclaims@agaltd.com. If you have any questions on claim submission please be sure to contact us at (631) 719-8027.

CREDITOR INFORMATION

Company Name *

Company Name Select *

Alt Customer ID *

Division/Region

Store Number *

Contact Name *

Telephone

Fax

E-mail

Address

Address 1

Address 2

City

State/Province

Zip/Postal

Country

DEBTOR INFORMATION

Company Name

Contact Name

Telephone

Fax

Secondary Telephone

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal

Country

PLACEMENT DETAIL

Please Accept This Account For

Do you possess a signed credit application for this debt?

Yes

Balance Due *

Currency

Date of Last Sale

Reference Number

Customer Number *

DOCUMENTATION

Please submit any contracts, notes, returned checks, itemized statements or other papers that are needed. When necessary, you are authorized to forward this account, under bond, to a commercial attorney.

File Upload

Maximum file size: 10MB

You may attach up to 5 files (10MB each) to this submission.
Acceptable file formats include MS Word/Excel, Apple Pages/Numbers, PDF and Zip files.

If you are human, leave this field blank.

SINGLE PLACEMENT FORM

CREDITOR INFORMATION

DEBTOR INFORMATION

PLACEMENT DETAIL

DOCUMENTATION